Social Work Exam Review

29-Indicators of Danger to Self

2010-12-22T11:51:00.002-05:00

Indicators of Danger to Self

Determining whether or not a client is suicidal can be stressful to a new provider. Fortunately, guides and indicators are available to assist in making the best determination possible. However, when dealing with humans, the best indicators, preparation and planning can fail. As a clinician, being conscious of that fact and facing it ahead of time is important for stress inoculation.

When evaluating suicidality in a client, it is important to be direct. Ask the client, “Are you suicidal?” or “Do you want to die?” or “Are you planning to kill yourself?” Naming it will not make the person suicidal but may open a dialogue and make it safe for the person to begin to share about the turmoil going on within them. Additionally, a desire for death does not mean active suicidality. The three questions above all indicate a different level of lethality. Suicidal now requires one set of actions, a plan to kill oneself requires another and just the desire to die yet another.

Symptoms to explore for suicidality include: depression (difficulty sleeping, appetite changes, loss or gain in weight, anhedonia, apathy, isolating), other mental disorders, feelings of helplessness and hopelessness, exhaustion, disorganization, confusion, difficulty concentrating, substance-abuse disorder, and feelings of guilt, shame, remorse, anger, rage, revenge and embarrassment.

Stressors to explore for suicidality include: recent loss by death, divorce or separation (1-3 months); loss of job, money or status; criminal involvement or threat of prosecution; family history of suicide; family history of mental disorder or substance abuse; family violence; physical or sexual abuse; firearms in the home; recent changes in life circumstances or environment, successes, increased responsibilities or promotion; exposure to suicidal behavior of others (family, peers or even media/role models). Lack of resources is often in the constellation of indicators for suicidality-if the individual has no resources for help (family, friends, employment) or they have family or friends available who are unwilling to intervene or assist.

Exploring the duration of the person’s situation is important. If the individual has a sharp or sudden onset of their current feelings or situation, the threat is of more concern. Explore if feelings are a recurrent outbreak of similar feelings or issues from the past, a recent increase of long-term traits or issues or if there is no discernable change in events. Acute changes are a greater indicator of danger than chronic conditions.

The individual’s medical status may demonstrate a chronic or debilitating illness, or there may be a new diagnosis of an illness (cancer, cardiac issues). Even if the illness has been present for some period of time, the chronic nature may have taken a toll or pain associated with the illness may have overtaken the person’s healthy coping skills. Exploring previous attempts with therapies or repeated unsuccessful experiences with professionals (physicians, social workers, psychologists) may also be an indicator of helplessness contributing to danger to self.

Suicidal communication is an obvious indicator of danger but should be mentioned. Also, meaningful communication with others that has been broken off and efforts to re-establish the communication are denied. If the individual focuses on guilt, shame or worthlessness, or seeing no alternatives, a problem is evident.

Suicidal plans: All plans must be taken seriously and acted upon for safety. It is a MYTH that people who talk about suicide will not make an attempt on their lives. With that understanding, there are some plans that are more lethal than others. The most lethal category is use of a gun, hanging or crashing a car. Next is a plan to use carbon monoxide fumes, take poison or other drugs. The least lethal is a plan to cut wrists or take aspirin. Availability of the plan is necessary to know, as well. For example, if an individual says they are suicidal with a plan to use carbon monoxide poisoning, but do not own a car and live in the heart of a city where they and their primary support system rely on public transportation. Availability of plans in terms of lethality must also be considered, with high lethality being accessible gun or pills available or in hand, followed in decreasing lethality by: knowing where to purchase or obtain the means to their plan, just has not done it yet; has worked out a plan in detail and has a time in mind; has a general idea but lacks specifics in the plan; has a bizarre or unusual plan that sounds unreal or phony; or has no plan, says “I’ll think of something.”

Past behavior is also an indicator of future behavior. If someone has had a previous suicide attempt, they are at greater risk of a future attempt, especially if that attempt was of high lethality. If they have a close relative attempt or commit suicide, the odds of being a danger to self rise, as well.

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27-Impact of Life Stressors on Systems

2010-12-16T10:14:00.000-05:00

Impact of Life Stressors on Systems

Life stressors can impact any human system, physical, mental, emotional, social or spiritual. Life stressors generally fall under one of six categories, including relationship issues (conflicted marriages, parent-child relationships, strained friendships), health status issues (coping with disease itself, impact of illness on relationships and budget, impact on ability to cope), career status or events (emotionally abusive environment, unrealistic demands, job that is a bad match, concern about layoffs), finances, personal safety (for self and family) and home life issues (chores, childrearing, home improvements). Any one of these issues can wreak havoc on an individual’s biopsychosocial systems. Conversely, life stressors can also provide the impetus for increased productivity, allowing one to perform at his/her optimal peak.

The stress response is a biological function, often referred to as the “fight or flight” response. The Autonomic Nervous System (ANS) is the control system, operating largely without consciousness, controlling visceral functioning necessary for “fight or flight” activities, acting to increase heart rate, blood pressure, muscle tone, breathing, reading the gastro-intestinal tract for survival by expelling unneeded waste (bowel/bladder functioning is part of this), increased pupil size and other functions related to increasing survival awareness and ability to adapt and overcome a perceived threatening situation. When the body perceives a stressful situation, such as being in the path of an oncoming car, the Sympathetic Nervous System (SNS), a component of the ANS, engages to provide the necessary functions for survival. As a note, breathing may be controlled by both conscious awareness and control in addition to being a part of the ANS, making it a component for use in relaxation and stress response training.

The ANS has a second portion to complement the SNS called the Parasympathetic Nervous System (PNS). The PNS engages after the perceived danger has passed. As the name “para” implies, the PNS works alongside the SNS as a balance, bringing the ANS back into balance once the perceived stressor is neutralized by reducing the heart rate and blood pressure, increasing tone and flexibility of muscles, decreasing respirations, returning full control of bowel and bladder functioning, returning pupils to normal size and countering any other systems that were altered to deal with the situation. Stress can be a positive. For example, having the ability to get out of the way of a moving car or having additional stress when preparing for and delivering a presentation can create optimal performance rather than coming across as listless or apathetic.

When the individual encounters multiple life stressors, the body’s SNS works in the same way, dropping stress hormones, such as cortisol and norepinephrine, and altering glucose levels in the body, and triggering the same reactions in varying levels to prepare for survival. Under chronic conditions, these hormones and alterations in body chemistry, which trigger the SNS to create a situation of chronic stress, depleting the body’s ability to fight physical illness and impairing the biological system.

Stress does not stop at the biological system. When life stressors are present, cognitive capacities are also compromised. The SNS reaction is reallocation of the body’s resources for survival. Higher level reasoning and other frontal lobe activity is not necessary for basic survival, so if you have ever wondered why you were forgetful when you were under stress, this is why. Your body was allocating needed resources for survival elsewhere.

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26-Indicators of Crisis

2010-12-08T10:44:00.000-05:00

Indicators of a Crisis

Experiences in life are subjective for each individual. Therefore, what one person may experience as a crisis, another may not. The level of a person’s resilience, skill or experience will determine their subjective experience. However, there are factors that will determine an individual’s perception of whether or not an experience rises to the level of a crisis.

A crisis will be stressful and/or disruptive. If an event does not overwhelm the individual’s coping skills, the person is less likely to perceive the event as a crisis. If the event is not disruptive to their environment or functioning, it is less likely to be perceived as a crisis. However, an event that impairs the individual’s ability to function physically, psychologically or socially, or disrupts the environment has the potential to create a crisis.

A crisis may be in response to a hazardous event. Natural disasters, such as a tornado, hurricane, flood or tsunami can overwhelm an individual, community or region physically, psychologically and socially, creating widespread crisis conditions. Natural life events, such as the death of a loved one, birth of a baby, marriage, unexpected pregnancy or retirement can trigger crisis. Manmade, deliberate acts of violence can be particularly traumatic, such as sexual assault, arson, murder, and acts of war or terrorism. Other events commonly associated with crisis are adolescent pregnancy, sudden absence of a key family member (through divorce or military deployment), cultural dislocation, disabling or life-threatening illness or injury, and any other drastic environmental change.

An indicator that an individual may be experiencing a crisis is that he or she reports a threat. The threat may not be of a violent nature and involve the individual’s loss of a sense of integrity or autonomy, loss of a job, spouse, home, reputation or status. The threat may involve being a crime victim, experiencing gang violence, being in a war zone, witnessing or being a victim of terrorism or another violent event.

A challenge to the individual may indicate a crisis. If the individual experiences a challenge that involves anxiety over the possibility of failure in the immediate future, a crisis can result. The challenge may be not performing adequately on a new job or failing an exam that is crucial to the individual’s future.

Losses often trigger crisis. Asking if the person has experienced a loss that resulted in emotions associated with the grieving process or involved with an acute sense of deprivation can uncover elements of a personal crisis. Issues associated with death, divorce, or moving away from one’s homeland are examples of triggers for this type of crisis.

Individuals who typically function at a high level find themselves unable to cope with seemingly minor tasks. When in crisis, the body musters all resources toward survival. Non-necessary survival activities are considered irrelevant and the brain does not attend to them. So, people find they cannot remember simple things, such as three items for the grocery store. Crisis may be marked by confusion, depression, physical symptoms (gastro-intestinal upset, headache, nausea, difficulty breathing), anxiety, anger or impaired social functioning.

During a crisis, individuals have a sharp reduction in their overall ability to cope. Problem-solving skills are limited, and they are vulnerable to further psychological stressors. The ability to defend themselves is decreased, making them an easy target for scam artists, such as during Katrina, falling prey to those offering easy money when financial times are hard.

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25-Effects of the Environment on Client System Behavior

2010-12-06T11:02:00.000-05:00

Effects of the Environment on Client System Behavior

The impact of client behavior can be partly understood via the examination of the environment in which the client exists. This is often referred to as the ‘person-in-environment’ or PIE concept. In this model, the individual is considered to be in constant interaction with any number of systems within their environment at any given time. Systems include family, friends, religion, politics, educational systems, workplace, marketplace, internet/social networking, social services, the legal system and more. The person is conceived as having dynamic involvement with each system. With this framework, addressing the various systems in which a client interacts can then impact the person’s behavior.

Eco-systemic Theory, also referred to as Bronfenbrenner’s Ecological Theory, puts forth the belief that human development is reflective of environmental systems. Five of such systems are defined, including the micro-system, meso-system, exo-system, macro-system and chrono-system.

The micro-system is the setting where the person lives. This context includes the family, school, friends, peers and the neighborhood. In this setting, the individual has the most direct forms of social interactions, such as with parents, partners or teachers. The person is not a passive element in the environment but rather, an active participant, shaping the events and the reality.

The meso-system is the relationship between micro-systems or link between contexts. This is played out in the relationship between the family experiences to school experiences, school experiences to sports experiences, sports experiences to church experiences, and church experiences to peer experiences. In this context, a child who has been rejected by his father may have trouble developing a positive relationship with the teacher in the classroom or difficulty with a teacher may disrupt development of trust with a coach.

The exo-system involves connections between the person’s immediate context and someone in a setting where the person does not have an active role. An example is when a spouse is impacted by his/her partner’s experiences in the workplace. In such a case, a departmental expansion may require more travel or longer work hours leading to greater stress, which in turn, may increase conflict in the home or alter patterns of communication or cherished routines.

The macro-system is the context of the person’s culture where they live. This includes such things as relative poverty or wealth, socioeconomic status, ethnicity, religion, political system and developing and industrialized countries.

The chrono-system involves the pattern of environmental transitions and events over the individual’s life, including socio-historical events and circumstances. An example of an environmental transition is divorce. The impact of divorce disrupts the environment, usually detrimentally for children when considering emotional and economic issues. This impact lessens over time with a decrease in chaos and an increase in stability. A socio-historical circumstance is the recent opportunity for homosexual individuals to marry in some states, and another example is how over the past 30-40 years there have been increased opportunities for women and minorities in the workplace.

Much of the impact on the client system is determined by the client’s ability to adapt to their surrounding environmental conditions, specifically how they adapt or change to new conditions and circumstances in order to continue functioning and surviving at a desired level. Additionally, people are not just affected by their environments; they impact and change their environments, often to increase their ability to cope more effectively. Coping is a part of adaptation involving the ability to identify and then alter behavior, attitude or circumstances to overcome a problem.

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24-Biopsychosocial Assessment Example

2010-11-30T10:28:00.000-05:00

Example-Biopsychosocial Assessment

The following is an abbreviated example of a BPS Assessment to demonstrate the basic components and content.

IDENTIFYING INFORMATION: Jane M. is self-referred 28 year old, divorced Caucasian female with no children or history of pregnancy seeking treatment to deal with feelings of hopelessness and depression.

PRESENT PSYCHIATRIC ILLNESS/SYMPTOMS: Client reports episodes of crying daily for the past month, difficulty focusing at work, inability to do chores at home (laundry, cleaning), isolating from friends and family, weight loss of 15 lbs in the past three weeks without dieting, insomnia (sleeping an average of 4-5 hours in 24), some thoughts of death, “it would be easier if I were dead”

PAST HX OF TREATMENT: Client reports one prior episode of major depressive symptoms three years ago for which she sought psychiatric care from Dr. Smith and underwent pharmacotherapy for 6 months with success, denying side-effects with the use of Paxil. She also reports attending a self-help group at her church and finding the support helpful. During her sophomore year in high school, she saw a school counselor for a few times following the separation and divorce of her parents to help with coping skills and grief/loss issues.

MENTAL HEALTH MEDICATIONS: No current use, previous course of Paxil with good efficacy, two trials of other medications during the same time that were unsuccessful. Client agrees to a release of information to seek additional information from Dr. Smith.

MEDICAL CONCERNS: Client reports recent gastro-intestinal upset, frequent diarrhea, nausea and headaches for which she has not sought medical attention. She denies any significant medical history, surgeries, pregnancies or disabilities.

CURRENT MEDICATIONS: Client reports taking over-the-counter anti-diarrheal medications and NSAID pain relievers.

DEPENDENCY/ADDICTION HISTORY: Client reports first use of alcohol at age 17, drinking two beers at a party and becoming intoxicated. She denied enjoying the experience but reports continued experimentation with alcohol one or two times per month until college when she stopped drinking following a binge-drinking episode prior to leaving for college in which she reports drinking until she began vomiting. Following that incident, she reported finding alcohol offensive. She did not drink again for five years. She now reports drinking primarily at holiday occasions, one to two servings, with choice of alcohol as wine. Last use was two months ago, one glass of wine at a holiday party. No current abuse or dependency issues suspected.

Client reports experimentation with cigarettes in high school when her parents divorced. She did not like the taste or smell and reports they made her lungs hurt, so she did not continue.

Client reports regular use of caffeine, up to five beverages per day of coffee and sodas.

FAMILY HISTORY OF PSYCHIATRIC/ADDICTION ILLNESS: Client reports her father suffers with clinical depression and her maternal grandmother and aunts drink alcohol to excess. She denies either of her parents ever drank in front of her, but she reports the belief her mother drinks and hides her alcohol, once finding a bottle of vodka in one of her mother’s shoe boxes.

SPIRITUALITY: Client was raised in a non-religious home but attended church with a friend in high school. She found comfort in the protestant church and has continued attendance and involvement. She reports inability to be involved when her symptoms are active, including inability to attend services, read her Bible or pray. She does have a support system at church who she reports call on her.

PERSONAL HISTORY: Client is the oldest of three children whose parents divorced when she was age 14. The parents remained in the same town and the children split roughly equal time between homes, experiencing considerable verbal conflict between mom and dad. She reports feeling responsible for their divorce, believing she did not help enough around the house, forcing her parents to be overworked and over-stressed because both worked outside the home. Mother was a bank-teller and dad was a plumber. Mother remarried within one year, having two more children. Client is now estranged from her mother and has limited contact with her father, despite living in the same town. She sees her younger siblings twice yearly, Christmas and 4th of July.

EDUCATION: Client completed high school and college with a degree in business.

WORK HISTORY: Client currently works in sales but has had a sharp decline in performance over the past month and is in jeopardy of losing her job due to her inability to focus. She has worked steadily since completing college in positions of increasing responsibility. During highs school and college, she waited tables.

LEGAL HISTORY: Client has no history of legal involvement and no pending legal action.

MARITAL/RELATIONSHIPS: Client married at age 22 to her college boyfriend, but they divorced three years later following what the client called “failed communication and an inability to get along.” She reports a history of brief relationships that end because she does not believe they are sustainable for the long-term. She denies any violent relationship, physically, verbally or emotionally.

MENTAL STATUS: Client appears casually dressed, neatly groomed and is cooperative. She is calm and there is no evidence of tremors, tics or muscle spasms. Her affect is appropriate to the conversation, and her mood is depressed. Speech is soft. Her thoughts flow logically and are organized with no perseverations, loose associations or thought blocking. There is no evidence of hallucinations or delusions. She is oriented to time, place and person. She does place devaluation on herself that is not supported by her situation.

SUMMARY IMPRESSION: Jane M. is a is self-referred 28 year old, divorced Caucasian female seeking treatment for recurrent depression that likely has a strong heredity component with possible contributing factors related to relationship issues and distorted beliefs about herself related to the divorce of her parents.

SHORT-TERM GOALS:

1) Refer to primary care physician to address ongoing GI symptoms client reports are uncontrolled for one month with OTC medications and to rule out any other medical etiology for symptoms.

2) Develop safety plan in case thoughts of death escalate to active suicidality.

3) Get client to engage in self-care plan discussed and written (see copy in chart).

4) Develop treatment plan during next session.

DIAGNOSTIC IMPRESSION:

Axis I:                Major Depressive Disorder, Recurrent

Axis II:         No diagnosis

Axis III:         Deferred, GI symptoms

Axis IV:         Difficulty functioning at work and home

Axis V:        (current) GAF 55

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23-Biopsychosocial History and Collateral Data

2010-11-29T10:36:00.000-05:00

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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22-Assessment_methods_and_techniques

2010-11-24T11:09:00.000-05:00

Assessment Methods and Techniques

The purpose of a specific assessment must be clear. Assessment is not to be done for assessment’s sake or beyond the disclosed purposes in informed consent. Social workers are bound by the NASW Code of Ethics (section 1.07 (a)) to respect client privacy, which means a social worker should never seek information out of curiosity or just because. The purpose of the specific assessment will drive the information sought. For example, if the assessment is court ordered to determine safety of a home, pending the return of children removed due to abuse or neglect issues, assessment will focus on safety, parenting, stress factors, coping skills, drugs and alcohol, attendance or completion of court ordered treatment and extended family supports. Great importance may be put on verifying information with secondary sources (records of attending treatment, drug tests, speaking with family). In another example, if the assessment is voluntary with an adult seeking treatment for depression, the assessment may include standardized depression inventory (i.e. Beck Depression Inventory) in addition to the clinical interview, with less requirement for external sources to verify the information given.

Many forms of recording assessment information are possible. One may use evidenced-based, user-led, form-led, standardized assessments or non-standardized assessment tools. Regardless of the type used, accountability is important. Evidenced-based practice is important because it allows the client and social worker to track change, and most payers, whether private insurance, publicly funded agencies, not-for-profit agencies, military medicine or other funding, a demonstration of progress is required for reimbursement. Evidenced-based techniques can be used with a variety of theoretical orientations; the issue is measuring behavior, mood or attitude and its subsequent changes.

Assessment done with an evidenced-based approach will expedite the setting of goals and treatment planning.

The assessment process should engage the client in the therapeutic process, creating a working therapeutic alliance on which to base treatment. The client has to feel comfortable enough to share the issues surrounding their presenting complaint and the issues that may have bearing on treatment planning, though they may not be the focus on treatment. The best way to engage the client is through rapport building throughout the assessment process.

It is important to listen actively, attending to both what is and is not said, as well as the client’s body language. Responding with full attention, reflecting what is being said and the deeper understanding of the client’s situation based on the client’s report, clinician observations and information gathered during assessment will assist in the rapport building process. Making culturally sensitive introductions and using the client’s preferred name during the session will also aid at putting the client at ease.

During the assessment session, it is important to check in with the client, either directly or indirectly, and to provide validation or normalize feelings, as appropriate. This technique allows the clinician to clarify the information and emotion shared, while also letting the client know he or she is being understood. If inconsistencies are present, addressing them can also be helpful but should be done with respect.

Assessing the clients communication patterns, as in neurolinguistic programming, can also be a useful tool in increasing rapport, individualizing the communication response, assessing the individuals subjective experience and empowering the individuals requisite skills to work together in the therapeutic alliance.

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21- Service_Delivery_Outline

2010-11-22T10:22:00.001-05:00

Service Delivery Outline

I. Formal Service Delivery Systems/Organizations
A.        Public agencies: mandated by law to provide income maintenance or other tangible goods and services
B.        Private Not-for-Profit: non-governmental, operating under specific legal guidelines regarding financial issues
C.        Private/Proprietary Agencies: non-governmental providing social services with profit motive
D.        Self-help Agencies: voluntary or mutual aid groups
E.        Independent Practice: proprietary, clinical and non-clinical activities (consultation, research, workshops)

II. Service Delivery
A.        Models
        1.        Social Competency
        2.        Social Change
        3.        Medical/Clinical
        4.        Educational
        5.        Ecological
B. Steps in Service Delivery
        1.        Engagement
        2.        Assessment
        3.        Planning
        4.        Implementation
        5.        Evaluation
C. Designs
        1.        Centralization vs. Decentralization
        2.        Single service vs. cluster of services
        3.        Coordinate efforts or operate alone
        4.        Employ professionals, para-professionals, consumers to provide services

III. Policies and Procedures
A.        Types of Policy
        1. Social/Family Policy
        2. Regulatory Policy
        3. Redistributive Policy
        4. Definitional Policy
B.        Purpose-Governmental (Federal/State)
        1.        Establish governmental agencies
        2.        Establish income maintenance guidelines
        3.        Establish parameters for services
C.        Purpose-Agency
        1.        Establish operations consistent with fed/state guidelines
        2.        Establish specific service delivery system
        3.        Consistent service delivery
        4.        Client rights, responsibilities and entitlements
D.        Implementation of Organizational Policy and Procedure
        1. Policy Implementation
         a. Secondary Legislation period requiring details about regulations, procedures and guidelines
         b. Impacted by agency limitations and capabilities
E.        Affects Service Delivery
        1.        Agency budget and resources
        2.        Staffing availability
        3.        Agency Capacity
        4.        Political climate

IV. Methods of Social Work Advocacy
A.        Policy Development
B.        Group Advocacy
C.        Individual and Family Advocacy
D.        Message-based
E.        Relationship-based
F.        Media-based

V. Interdisciplinary Collaboration
A. Multiple disciplines
B. Holistic approach to complex clients

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20-Assessment of Client System Strengths and Weaknesses

2010-11-18T10:23:00.000-05:00

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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19-Assessment_indicators_components

2010-11-16T11:03:00.000-05:00

Assessment Indicators, Components and Characteristics

Assessment is the process of collecting data; analyzing the nature, causes and triggers of client issues and problems; identifying strengths; reviewing the progression of the clients context; synthesizing the clients relevant data; and formulating an intervention or action plan accordingly. Components of the assessment will be driven based on the situation and may include different information based on the situation.

The components of good practice are thorough knowledge, social work values, professional ethics, proficient skills and complete process. Within a good practice milieu, one has the ability to conduct meaningful assessment. Assessment must be functional to the setting and context of the individual, family or group. Necessary components are: how the client came to be referred (self-referral, court-referred, urged by family member), how the client identifies the problem(s) or issues(s), how others view the problem(s) or issues(s), client system strengths and weaknesses, indicators of abuse and neglect, indicators of dangers to self or others, indicators of crisis or resiliency for coping with crises, social history, appropriate collateral data, and any applicable assessment protocols (i.e. Structured Clinical Interview for the DSM-IV Axis I (SCID-I) or the SCID-II) or instruments (i.e. diagnosis specific scales such as a depression inventory or post-traumatic stress inventory, the NEO Personality Inventory-Revised or the OMNI-IV for personality disorder assessment).

Assessments should be both valid and reliable. Valid assessments are ones that measure and assess what is intended to be measured and assessed. For the most valid assessment, several tools are used to assess what is going on with the client. If a client is referred for depression, a valid assessment requires more than simply reviewing the symptoms present in the DSM-IV, though this may validate some symptoms. Increasing validity might include conducting a biopsychosocial assessment, a social history, a SCID-I, a depression scale and getting collateral information from a family member. Determining validity in the field of mental health is more difficult than in other areas of science, so being diligent, as is called for in our professional ethics and values, is necessary.

For an assessment to be reliable, it must be consistent in its outcome. Therefore, the use of non-standardized instruments in assessing for depression is not appropriate as it may lead to a diagnosis that is also not reliable, meaning that another professional would not confirm the diagnosis if they conducted a full clinical assessment using valid and reliable protocols and measures. While time and financial constraints may be present and necessarily limit the tools used during assessment, sufficient assessment components need to be present that are current in the literature and research, applicable to the setting and are well versed by the assessor.

The person conducting the assessment must also be familiar with the population served. While proficiency in assessment techniques is required, sufficient nuances are present in populations that call for unique knowledge and understanding to adequately apply professional assessment tool and standards. For example, someone not accustomed to working with a patient who has lost a limb may believe the individual is exhibiting the characteristic of a psychosis when complaining of pain in the missing limb, a occurrence commonly referred to as phantom pain that is well within the norm of this condition. Simple book knowledge of diagnostic characteristics is not sufficient to be proficient in diagnosing many populations because of issues specific to that population. The uniqueness may be culturally (Hispanic youth not making eye contact being mistaken for inattentiveness or disrespect), medically (newly diagnosed cancer patient appearing to have clinical depression or anxiety), experientially (war veteran back 6-weeks from duty making normal adjustments diagnosed with Obsessive-Compulsive Personality Disorder), spiritually (need to have a priest give Last Rites), or a variety of other issues.

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18-General_assessment_issues

2010-11-11T10:10:00.001-05:00

General Assessment Issues

The basis for any effective social work action is effective assessment of the problem or situation. A solid understanding of assessment issues is important to the success of case work, crisis management, clinical treatment, psycho education, community organizing, new parent support, child protection services, advocacy, policy development and any other issues that may be defined. It is the key to beginning an effective relationship with a client or starting any element of mezzo or macro practice.

The first part of the process in assessment is to determine why the client is present. The psychosocial summary should include a statement about what brought the client to the session, specifically the basis for the assessment. When the reason for the assessment is discovered, it drives who should be present for the initial meeting. For example, if parents call about a problem child, age 7, who is out of control, who should attend the first session? Should the entire family be present or some subset thereof? Further, what is observed in the waiting room prior to the initial session? Is the parent engaged with the child, dismissive, agitated, pacing, on the phone? Which member of the family seems eager to be present? Who seems anxious, angry or scared?

Confidentiality must be addressed prior to the start of assessment. If notes are taken during session, be open with the client about what you are doing, such as saying I need to have some specific information because some things may be hard for me to recall, like dates, names or events. The full parameters of what information can and cannot be kept confidential are important to provide. If insurance is being filed, it is important to make sure the client(s) understand what the insurance company can access and review or what is submitted to the company. If the client is involuntary (i.e. court ordered), make sure the client knows what is expected of them and how confidentiality relates to their status.

Often clients have curiosity about their social worker. After all, the worker is often actively engaged in the clients life and knows extensive information about the client. As a social worker, one must decide how personal questions will be addressed. This should be based on several considerations. One is agency policy. Does the agency have a policy about the disclosure of personal information with clients? Theory often drives how much information is disclosed and the meaning of the question asked by the client. Generally, it is important to understand the meaning of the question to the client. Some clients may ask a personal question because they want to know if the worker has experience in something going on in the clients life. Cultural issues may drive the clients question, perhaps wanting to learn about how a social worker from the dominant culture may relate to a client from a minority background. Other clients have a sincere curiosity about the person who is becoming a part of their life. Some clients have significant boundary issues. Most important is to understand the significance of the clients question and put the clients interests first. This does not suggest the client needs intimate details of a social workers life, but interpersonal sharing can begin healthy role-modeling for the client. If the worker is uncomfortable sharing any personal information, the worker must negotiate that, as well. The worker can still set the tone for a positive relationship by setting a boundary that does not include sharing personal information by responding honestly, such as I am not comfortable sharing about my personal life with you, but I want to understand what that question means to you or if you feel I can help without answering personal questions.

The timeframe for assessment may very across settings. Requirements present in a governmental agency may be different than in a non-profit agency setting or an independent practitioners office. An inpatient unit may require assessment to go very quickly because the turn-around time for the client is fast, while a residential program may allow for assessment to be done over two or three sessions, resulting in a more in-depth assessment. The payer (i.e. insurance, private, self-pay) often dictates the limits or flexibility allowed in the assessment process.

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10-Information_Gathering

2010-11-09T10:22:00.000-05:00

Information Gathering

Information gathering for assessment and throughout the treatment process to termination is vital and may be done through a variety of means. Effectively trained social workers can ascertain accurate and useful information through the social work hallmark of the biopsychosocial assessment, a psychosocial history, structured Diagnostic and Statistical Manual of Mental Disorders, 4th, ed. (DSM-IV-TR) decision tree or algorithm, psychological testing, collateral data and a variety of non-standardized measurements. An interviewer can use visual and auditory observations for powerful cues and information about what is going on with a client, guiding where additional information or issues may need to be assessed. Olfactory cues may also be relevant to assessment. Additionally, it is often what a client does not say, not just what is said, that is telling information about what is going on with a client or client system.

The correct tool for information gathering will depend on the client and the context of the situation. However, in almost all instances outside of a crisis or disaster/trauma response scenario, it will be appropriate to take a biopsychosocial history and complete a mental status exam. These two elements will provide for a basic picture of the client in their context and allow for educated planning for further assessment or case disposition.

Briefly, the biopsychosocial assessment is a tool that provides the clinician with information on the current or presenting issue or issues, the clients past and present physical health, including developmental milestones, the clients emotional functioning, educational/vocational background, cultural issues, spiritual and religious beliefs, environmental issues and social functioning. Each issue may be reviewed for its relationship or impact with the presenting issue.

The Mental Status Exam (MSE) is a structured approach to attain a comprehensive cross-section of the clients state of mind. Areas specifically explored include speech, thought process, thought content, perception, cognition, judgment, insight, mood and affect, behavior, attitude and appearance. Information is gathered through unstructured observation and direct interaction. Sometimes individuals confuse the MSE with the Mini-Mental Status Exam (MMSE); however, the two instruments are very different psychological tools. The MMSE is a brief neuropsychological tool used for quick assessment and screening of dementia.

These two protocols provide educated guidance for which DSM-IV-TR diagnostic decision tree or algorithm to use. If a formal diagnostic assessment is not the purpose of the interview, such as in disaster response or other crisis oriented intervention, the MSE can guide crucial intervention strategies that may prevent both imminent pitfalls and minimize long-term detrimental effects.

Additional information gathering to supplement client self-report in the primary protocols reviewed may be required. While clients may be forthcoming about their situations, they may have reasons not to be honest, such as fear of being disliked, shame, lack of trust, desire to please the clinician, fears of retribution, distorted thinking, legal concerns and a constellation of issues that may relate to being an involuntary client. Because self-report is flawed, having collateral sources of information can be invaluable. Sources of collateral information may be a significant other, teacher, parent, other family member, spouse, employer, hospital discharge summary, medical records, caseworker or many other sources. Remember, it is vital that permission is received from the client and documented appropriately (release of information, parental permission with release of information).

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9-Social_History__Collateral_Data.txt

2010-11-04T15:49:00.000-04:00

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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The Licensed Clinical Social Worker Exam: What would you do first?

2010-05-31T11:08:00.000-04:00

The Licensed Clinical Social Worker Exam: What would you do first?

8-Interdisciplinary_Collaboration

2010-04-29T16:53:00.000-04:00

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 MaryÕs use of pushing otherÕs 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.

7-Staff_Development

2010-04-27T16:53:00.001-04:00

Staff Development

Staff Development within an organization is key to promoting professionalism and keeping current on professional development. It is also another means to provide incentives that are low cost or cost neutral to the organization, aside from time away from work activities, but are meaningful to the social worker, limiting out-of-pocket expenses for maintaining their professional license. Additionally, it is a tool for morale building and to address specific issues as they arise within the organizational culture, both those that directly and indirectly impact client care.

During times of change or noted trends in a community, such as closing of a key industry or factory, development of a major health issue, or an upsurge in violence, staff development could offer the perfect opportunity for a supervisor to develop or bring in an expert on the subject area to provide training and development in the topic area, offering insight on the impact of the issue and specific knowledge, skills and strategies for addressing issues that directly impact the organization and its clients. It may also be a part of long-range planning for bigger issues, such as disaster planning.

Staff development assists the organization in forward planning on multiple levels when change occurs or negative events happen. Attending to professional development of social workers can reduce stress by augmenting skills and resources, as well as creating a greater sense of community and support. When negative environmental impact can be anticipated, professional development can assist in bolstering targeted interventions provide the opportunity to network with others for appropriate referrals and resource building.

Example:
A large aerospace engineering company anticipated layoffs in the coming weeks. The sheer numbers anticipated would impact the communityÕs economy on all levels, with layoffs occurring throughout the company, from plant workers to senior executives. The impact would be felt by not only the company, but also supporting industry businesses (i.e. suppliers) and community businesses (e.g. restaurants, grocery stores, retail chains, movie theaters). The Office of Unemployment anticipated an influx of people filing claims, and the local director was concerned about the impact on his caseworkers and front-line staff when the news broke and people began arriving. He met with his management and human resource staff and organized professional development to provide training and development for the staff to deal with what he knew would be a stressful period. Additionally, he networked with the local welfare office and community organizations that provide job-related services to assure his office has the most current information to provide. In the process, he learned about additional resources and was able to streamline referrals for clients in need of retraining and received information for veterans. When the training was offered, he had a plan in place for addressing the influx of new claims, offering support for increased employee stress levels and community professionals who were willing to provide monthly in-services to staff on issues such as stress management, addressing workplace conflicts, anxiety, anger management and related topics.

In the example:
The director took proactive steps to build the staff up and prepare them for a situation that would likely take a toll on them. Even if the incident were avoided, the staff would benefit and the community links made would benefit the overall system. The demonstration of professionalism is entirely consistent with the NASW Code of Ethics, with functional demonstration of role modeling, staff support, collaboration and leadership.

6-Consultation.txt

2010-04-27T16:53:00.000-04:00

Consultation
Consultation and supervision are often used as interchangeable words. However, they are very different processes for key reasons. Consultation is the model or process by which one practitioner seeks out the advice or recommendations of another. While supervision may appear on the surface to be the same, the key difference is that in consultation there is no official sanction to the relationship. In the process of consultation, there is no requirement for the seeker of the information to follow the recommendations or responses given. Additionally, unless otherwise specified, there is no administrative responsibility or accountability compelling the person in receipt of the consultative services to follow the counsel or recommendations set forth by the consultant.
Conversely in the relationship, if problems arise, the recipient of the counsel or recommendation in a consultant-social worker relationship does not follow through on information provided or recommendations made, the consultant has no power in the relationship. A consultant does not have the responsibility, accountability or authority to compel the social worker to change course or to implement a course correction or sanction against the social worker. As a supervisor, whether of a student or employee, that individual would have the responsibility and accountability to do so if the supervisee does not follow the recommendations as set forth.
Consultants are often retained by experienced social workers for their specific expertise in a particular area and develop and ongoing relationship to for case review and consultation. Experienced social workers are expected to know when such services are needed or required on a self-determined or as-needed basis. Federal or state requirements may mandate consultative or supervisory intervention in the social worker's state of practice.
Experienced social workers are also encouraged by the NASW Code of Ethics to mentor and share their expertise to other social workers. Experienced social workers are encouraged to pass on their knowledge and skills to organizations, groups or individual social workers through mentoring and training opportunities. This assists in maintaining the integrity of the profession, while also enriching the fabric of providers.
Example:
Connie was hired by The Children's Center to consult with the counseling department. She is an expert in cognitive-behavioral techniques with children, and has pioneered a new protocol for dealing with behavioral problems in the school setting. The counseling staff has experience in a variety of techniques, and appreciates the opportunity to learn different ways to deal with challenging and complex cases. Jennifer presented a case: Sara, age 7, who has difficulty with her schoolwork, following directions at school and at home, violent outbursts with family members, physical altercations with peers and authority figures at school, and great difficulty drawing her out in session. Jennifer is trained in play therapy. Connie made recommendations specific to her new, proven protocol. Jennifer attempted to follow the recommendations, but had little success in the following four sessions. Jennifer returned to her treatment format in which she was comfortable, knowledgeable and accomplished in her interventions, but made some alterations based on the group's consultative feedback.
In this example:
Jennifer sought the consultation of Connie in the departmental group. She did not have success and returned to what was familiar and consistent with her training, but with some of the new ideas integrated into her style. Jennifer is an experienced social worker and is not bound by a consultant to alter her treatment methods. However, she can enrich her practice by learning new techniques and her clients will likely benefit from her expanded knowledge base.

5-Social_Work_Supervision.txt

2009-12-20T02:13:00.000-05:00

Evolution of Social Work Supervision Model

Social work supervision was originally based upon the medical model, with physicians teaching in early social work training programs and serving on boards and in charitable organizations with input on how such organizations operated and were structured. The concept of supervision in the organizational setting dates back to early social work educational programs. In agency-based apprenticeships, a new worker shadowed an experienced worker who modeled skills, behaviors and attitudes required to be an agency social worker.

Primary education of social workers transitioned into the university and other educational settings at the turn of the 20th century. While theory and basic skills training and teaching shifted to educational institutions, primary field training continued in a variety of agency and organizational-based settings. Subsequently, different forms of supervision developed over time.

The Clinical Supervisor has the authority and is under assignment to assist and direct the practice of a social worker in the areas of teaching, supporting and administration. Models that may be observed are varied, each with different elements of focus. The Task-Centered Model contains the three basic elements of education, administration and support. The Discrimination Model centers on the elements of process, conceptualization and personalization. The Developmental Model centers on three levels (beginning, intermediate and advanced), each with varying degrees of awareness, autonomy and motivation, and eight identified growth areas for each supervisee. The Contemporary Field Instruction Model of supervision is characterized by the supervisee's case needs, focusing on case planning and problem solving as a primary area of work. The Articulated Approach to supervision focuses on systematic integration of information from the classroom and field placement. The Andragogical Approach to supervision is characterized by learner-directed goals and objectives, has a focus on addressing immediate challenges, as opposed to subject-centered learning and is built around an egalitarian supervisor-supervisee relationship.

Regardless of the format of supervision chosen, certain elements remain crucial for effective supervision to maximize results and minimize liability. The five most important characteristics or elements of effective supervision are that it is structured, regular, consistent, case oriented and evaluated. Using a "structured" approach to supervision, the supervisor has clarified the format in which supervision is conducted, such as group supervision or individual supervision, or a combination thereof. The term "regular" in this context means that supervision is formalized into a schedule and conducted on a standard basis, such as weekly, to avoid infringing on or skipping supervision altogether. The term "consistent" in this context is the approach and style of the supervisor is constant, with a logical connection between the pattern and style of the decision making process, thereby setting up a means to consider approaching a given situation while not being distracted by how the supervisor may or may not react. The term "case oriented" in this context refers to the need for extraneous matters to be limited and the focus maintained on the case material, and all discussion of administrative, personal and learning issues should related to the case, either a specific case or a general case discussion. As a characteristic of effective supervision, "evaluated" refers to formal or informal evaluation of the supervision provided and supervisory process itself.

In any given setting, any number of approaches may be effective in serving both the supervisee and the client. The style is less important than the need for consistency and professional protocols.

Attachment Theory

2009-11-09T09:33:00.000-05:00

Attachment theory explores the relationships between humans using psychological, ethological and evolutional theory. John Bowlby, a British psychoanalyst and psychiatrist who lived from 1907 to 1990, created the original theory. The central tenet is the belief an infant needs to develop a relationship with one or more primary caregivers for normal emotional and social development to occur.

Bowlby believed in four basic, distinguishable characteristics in attachment. First is Proximity Maintenance. This is the desire to be close to the people to which we are attached. Second is Safe Haven. This is safety or comfort seeking with the attachment figure when feeling threatened or fearful. Third is Secure Base. Secure Base implies the attachment figure is a place the child can use and return to when exploring the surrounding environment, comforted that there is a place of security that acts as a touchstone, if needed, in which to return. Fourth is Separation Distress. This is the occurrence of anxiety when the attachment figure is not present.

Bowlby associated infant behavior with seeking proximity to an attachment figure (trusted caregiver) in situations of stress. The trusted caregivers establish Proximity Maintenance. Infants then become attached to caregivers who respond to them and are constant in their lives, especially from ages six months to two years, because they create a Safe Haven. As children approach the age of two, the child uses the attachment figures (caregivers familiar to them) as a Secure Base. The infant who is attached has an adaptive response of Separation Distress or Separation Anxiety when the attachment figure departs. This mechanism is an apparent survival mechanism for the child.

Initial criticism of Bowlby’s research came from the psychoanalytic community because of the departure from the predominant theory of the time. Later criticism came out of other disciplines after extensive empirical research surrounding the development of infant/child close relationships. However, the basis concepts associated with the theory have remained and serve as the foundation of theory, as well as the formulation of policy and practice in the arenas of social policy as it relates to children and childcare to enhance the attachments in early childhood.

Mary Salter Ainsworth, an American Developmental Psychologist who lived from 1913 to 1999, focused her work on emotional attachment. Through her research, she developed attachment patterns observed in infants: secure attachment, anxious/avoidant attachment and anxious/resistant attachment. She observed infants who experienced distress when their mother departed and sought comfort upon her return, referring to this as Secure Attachment. Ainsworth observed a lack of distress upon a mother’s departure from her infant and avoidance at her return, called Anxious/Avoidant Attachment. Ainsworth’s third category of observations involved a pattern of proximity to the mother in the initial minutes alone, followed by high levels of distress at mother’s departure, seeking comfort upon her return, followed by rejection at the closeness. She referred to this third category as Anxious/Resistant Attachment.

A fourth category was later theorized, called Disorganized Attachment, theorized by Mary Main and Judith Solomon. Disorganized Attachment resembles the Anxious/Avoidant infants/children, but had significant ambivalence upon reunion with the caretaker, both approaching and avoiding. Bowlby described this as pulling away with anger while seeking to be close.

1-Educational Functions of Supervision

2009-10-22T21:00:00.001-04:00

Mary Richmond, the early pioneer of social work, directed the first coursework related to fieldwork supervision in 1911 at the Russel Sage Foundation Charity Organization Department, establishing the first formal social work supervision training. By the 1920, the pivotal shift was made from human service organizations having the explicit purview of educating social workers to colleges and universities doing the primary training. The educational component of supervision allows for the instilling of values, core principles, knowledge and skills of the social work profession. The three primary functions of effective social work supervision are educational, administrative and supportive. Education is, by far, the most important functional element of supervision.

The educational function of supervision seeks to contribute training and knowledge to enhance theoretical understanding, aid in shifting attitudes when and where needed, and to advance methods of work, enabling social workers to set and achieve worthwhile goals. This process lends itself to instilling social work core values and principles throughout, allowing for professional development on multiple levels. Supervisors are charged with ethical practice, which includes having the full professional knowledge and skills required to provide technical expertise, as well as to role model social work values and ethics.
Prior to initiating supervision services, a good supervisor will conduct a thorough and compete educational assessment. While the completed coursework and use of nomenclature may be useful in determining the needs of a supervisee, a full understanding of what the supervisee has experienced may be a better indication of what he or she has actually internalized in the context of experience, practice style, strengths and weaknesses. The effective supervisor will then focus on areas of strength, using positive feedback and positive reinforcement, and begin to build upon existing skills to address deficit areas. Unskilled supervisors may make the mistake of beginning with deficit or weakness areas. This technique may destroy confidence and decrease the establishment of trust, especially early in the supervisor-supervisee relationship. Specific goals should be set to measure progress.

Supervisees can better learn when they have a specific structure in which to organize their learning about the treatment process. One way clinical supervisors may structure the supervisory process is by breaking down the learning process into three components, specifically (1) treatment structure, (2) treatment content and (3) intervention process. Each of these components may be further dissected and be an area of focus in building upon social work skills.

In working with a supervisee on treatment structure, the supervisor may focus supervisory sessions on specific structural techniques to best organize treatment, such as session length, specific type of therapy, location of sessions or the use of contracting. In working with supervisees on treatment content, the supervisor may focus on elements specific to the client case, helping the supervisee ferret out the most meaningful content provided by the client or discover what the client has omitted or minimized in disclosure. During the intervention process, the supervisor may focus with the supervisee on any number of intervention processes, helping the supervisee determine which is best based on the client needs, client development level, treatment setting, available time or other factors.

The function of educational supervision is vital. It is crucial to remain relevant and effective to the population served, to developing the social work profession, and to raising the next generation of social workers.

4-Reducing_Vicarious_Supervisory_Ri_.txt

2009-10-19T16:52:00.004-04:00

Reducing Vicarious Supervisor Risk
Supervision is a vital element in the practice of social work. Supervisors provide advancement of the social work profession, develop individual social workers to perform with professionalism and protect clients. The focus of this work is done in multiple ways, depending on the environment. In some settings, the supervisory process may be very complex, functioning in multiple supervisory roles on multiple levels, often at the same time. The supervisor may assign cases, monitor productivity, address disciplinary issues, implement administrative policies, access funding for critical services, establish departmental priorities and dealing with licensing audits may be activities that arise. All of these activities may occur within the scope of one day and require a specific skill set.
In complex settings, the supervisor may find him or herself overwhelmed by the extensive demands of the job and curtail supervision from time to time in lieu of competing demands. While temporary suspension of supervision may not seem to be problematic, it opens the supervisor to vicarious liability through actions of supervisees, both omissions and commissions. Court rulings have repeatedly underscored the need and crucial nature of adequate supervision.
Supervisors may minimize vicarious liability risks and maximize the likelihood of a favorable ruling in a malpractice suit through a variety of ways. A supervisor can clearly define expectations, set or follow standardized policies and guidelines, be aware of high-risk practice areas, provide pertinent training and structured supervision. To further reduce risks, the supervisor can fully assess the supervisee's performance strengths and weaknesses, document all supervisory sessions, develop a written supervisory plan, develop and use a feedback system and provide sufficient support for challenging cases.
Supervisors often get into trouble, entering into vicarious liability, via multiple activities. Some supervisors do not give adequate information for proper practice. Others do not adequately review supervisee work to assess for errors or progression of skill or skill level. Some cases require specialty care, beyond what a supervisee can provide, and the appropriate action, referral or intervention process is not put into place. A supervisor may not put coverage into place when he or she is not available or may fail to meet with on a regular basis. Supervisors are bound to relay information on the context of dual relationships as defined by the NASW Code of Ethics, but often fail to have a specific conversation about this issue or to deal directly with boundary violations, such as the exertion of undue influence, romantic issues or any other type of dual relationship.
Actions supervisors can take to reduce risk include the following:
* Put in writing expectations for supervisees, including the purpose of supervision, expectations for the supervisee, supervision plan with specific objectives, method of supervision, frequency/duration/format of supervisory meetings, how supervision relates to personnel evaluations, plan for conflict resolution, specific responsibilities of supervisor and supervisee, method for evaluation, termination process and applicable payment or fees
* Document all supervisory sessions, including dates, goals and objectives addressed, progress toward goals, and any recommendations made to the supervisee or client
* Include discussion about the NASW Code of Ethics and supervise in accordance with its values
* Set a reasonable standard for the supervisee and ensure he or she is performing beyond a minimal level
* Seek consultation when a case or supervisee issue is beyond the scope of practice or ability of the supervisor
* Make sure all appropriate releases are signed as required by standards of practice for supervision, including client informed consent and appropriate releases of information
* Maintain confidentiality with supervisory relationship, do not engage in dual relationships and provide fair evaluations

3-Supervision.txt

2009-10-19T16:52:00.003-04:00

Supervision
The Clinical Supervisor has the authority and is under assignment to assist and direct the practice of a social worker in the areas of teaching, supporting and administration. This task is to be undertaken with formality, in person and in accordance with state boards and their requisite social work requirements and the ethics of the social work profession. Casual exchange of day-to-day information over lunch, via the Internet or by phone does not meet the standard necessary for the profession.
In the clinical or educational role, the supervisor is to establish a learning environment in which the supervisee can gain the therapeutic skills and necessary self-awareness required to maximize learning. The focus should be on knowledge, skills, abilities and attitudes paramount to a social worker?s interactions with a client, group or specific population. The teaching should be centered on specific interventions and services to specific clients, families or groups being served.
The supervisor should be current on social work and literature relevant to the population served or treatment modality practiced. Additionally, they must have a systematic means of tracking literature to stay up on practice protocols and guidelines, and be knowledgeable about how to guide and refer supervisees to appropriate literature as indicated. Staying current on the literature is crucial and necessary to being relevant in the field with new social workers.
Some state regulatory boards and credentialing organizations may delineate specific requirements and definitions of supervision. Supervisors who take on the responsibility and accountability for clinical social workers should be familiar with the most current rules, regulations and definitions of supervision in their practice jurisdiction.
Effective supervision enhances the competencies of supervisees in executing quality client care through the provision of knowledge, skills and attitudes, as well as by guiding specific professional growth and development to maximize clinical outcomes. A supervision program aids in addressing unethical practices by exposing and exploring practice methods, thereby reducing the potential of abuse in the client-provider relationship.
Example:
Sarah is a clinical social worker with 15 years experience. Her practice is struggling in the current economy, so she has sought credentialing to become a clinical supervisor as a means of subsidizing her practice. She has taken on a dozen supervisees, and to maintain her necessary contact hours with each supervisee, she often meets with them via e-mail or on casual phone calls as both she and the supervisees are available. She believes this casual contact allows her to be closer to her supervisees, allowing them to feel comfortable bringing up difficult issues with cases and in personal reactions to cases.
In this example:
Sarah may or may not have appropriate motivation for electing to seek a supervisory credential through her state board. However, she is being highly inappropriate by taking short-cuts in utilizing e-mail and the telephone as a substitute for structured, face-to-face supervision. Her behavior is not ethical or professional, and if she documents the hours of "casual" contacts in the formal documentation toward licensing hours, she and the student may be in violation of the law.

2-Administrative_functions_of_Super_.txt

2009-10-19T16:52:00.002-04:00

Administrative Functions of Supervision
The Administrative function of supervision seeks to ensure the social worker completes tasks associated with agency policy and procedure, and provides a senior mentor as a resource. Agencies must promote and maintain high work standards, a cohesive marriage between practice and policy within the administration, and offer the assurance of efficiency during an era of shrinking dollars, growing accountability and the need to maintain high ethical standards.
Two key reasons for supervision in social work today are licensure and regulation. This raises the bar on the relationship between supervisor and practitioner, placing the onus on the supervisor (legally, professionally and ethically) to be both accountable and responsible for their actions and the activities surrounding supervision of those in their charge.
Administrative supervision is also the mechanism within the bureaucratic structure responsible for the recruitment and selection of staff. This mechanism goes beyond simple resume selection and "check the box" qualifications for hiring. Astute administrative supervisors select personal characteristics, maturity, traits and attitudes that will foster the employee to feel comfortable in accepting and implementing organizational goals and objectives.
Administrative supervisors have both short- and long-term functional goals with employment hiring. Examples of short-term goals are issues like providing information on travel reimbursement, agency operations, training requirements, organizational structure, supervisory structure and relationship between departments. Long-range planning functions include activities such as setting up a departmental budget based on estimated future workloads and required resources to meet the estimated fiscal, personal and technical needs.
Often supervisors play all three primary supervisory roles, educational, administrative and supportive. For example, the department supervisor may provide staff development and support through a variety of team building activities, educational supervision through weekly supervisory conferences and do the primary hiring, work flow management and departmental budgeting.
Case:
Joyce works for a women's organization that provides job readiness skills, employment classes, literacy programs and short-term counseling. Her funding base is diverse, with individual donors, corporations, United Way funds, government grants and some state money. The department directors of each program report to her. She requires each department head to report out specific statistics and reports, each of which she reviews and plugs into organizational reports for formal audits and reporting to the board of directors, the public and in accordance with requirements for each funding source. She also asks each one to look one and two years out, providing educated estimates of the needs each believes their department will have to assist her in creating an organizational budget to take to the board of directors.
When the director of the employment program left for maternity leave, the organization was left short-staffed with few options for coverage. Joyce filled in some of the department head duties, in addition to covering a class and providing support to the staff that were facing increasing numbers do to the downturn in the economy.
The example demonstrates how a person whose supervisory role is primarily supervisory, also functions in other supervisory capacities, as well as the important nature of administrative supervision.

Finally! Study on your iPhone or iTouch

2009-08-24T10:38:00.000-04:00

Have an iPhone or iTouch? You can now practice for your exam on your handheld using our question database. With our new app, you can design a quiz ranging from 5 to 25 questions at a time. Just like the real test, a small case study or question comes up with (A) (B) (C) or (D) answers to choose from. Questions are randomly chosen from our question database for your generated exam. Feedback is immediate, letting you know if you are right or wrong (many times also including an explanation as to the correct answer).

The Lite version is free but exams are created from a smaller data base of questions. The Pro version (Cost $12.99) constructs the exams from a database that is holds same number of questions that would be found in an actual exam.

Find iPhone apps at AppStoreHQ

Social Work Scholarship

2009-02-06T15:53:00.000-05:00

Hi - this is exciting - I've been working on this since Christmas and I'm pretty sure it's ready! I've just put together a SCHOLARSHIP PROGRAM to award a subscription to http://socialworkexam.com - If you're pinching pennies right now this might help out! I'll keep you posted on how it turns out!

With friendly greetings,

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Here is the URL:

Social Work Scholarship

The Licensed Clinical Social Worker Exam: Study Groups

2008-01-08T07:52:00.000-05:00

The Licensed Clinical Social Worker Exam: Study Groups

2007-11-08T21:16:00.000-05:00

Social Work Exam Review

Experiential Family Therapy (e.g. Carl Whitaker)

2007-08-07T15:11:00.000-04:00

A) Assumptions

1. Based on a pragmatic stance with the belief that theory can hinder clinical work
2. Each family member has the right to be themselves
3. Based on the belief of the family being an integrated whole, not as a collection of discrete individuals
4. Familial togetherness and cohesion is associated with personal growth
5. Emphasis on the importance of involving extended family members in treatment (especially the expressive and lively spontaneity of children)
6. Basis of this bold and inventive approach to family therapy was the result of Whitaker’s spontaneous and creative thinking
7. Stresses the importance of genuineness
8. Techniques are secondary to the therapeutic relationship
9. Whitaker believed in this a theoretical approach based on the assumption that many times, theory is way for therapist to create distance from clients; it also helps to control the anxiety of therapists by allowing them to hide behind their “theory”.
10. Emotional expression is thought to be the medium of shared experience and the means to fulfillment (personal and family).
11. Whitaker suggested that self-fulfillment depended on family cohesiveness.

B) Why People Do What they Do? (What Motivates Them?)

1. To be authentic and able to freely express oneself
2. Being autonomous while also feeling they are a part of the family
3. To have intimacy
4. Self-actualization and self-determination

C) How Do People Get In Trouble?

1. Symptoms and interpersonal problems stem from the lack of emotional closeness and sharing among family members.
2. The needs of the family may be suppressing the rights of the individual.
3. Keeping family secrets can lead to the dysfunction of family members.
4. The family has infringed upon its individual members’ growth and freedom.
5. Personal choice has been comprised.
6. Families put on a façade which restrains its members from being authentic.

D) How To Help People

Goals of Experiential Family Therapy
• The primary goal of experiential therapy is to reduce defensiveness and unlock deeper levels of experiencing by freeing the clients from their impulses.
• Goals for the family
o improved communication and reduced conflict
o growth, not stability: symptom reduction is secondary to greater freedom of choice
o increased personal integrity (congruence between inner experience and outer behavior)
o less dependence,
o expanded experiencing
o emphasis on the feeling side of human nature
o improved autonomy for each member
o improved agreement about roles
o merger of needs for individual growth and strengthening the family unit.
1. The therapist’s active and forceful personal involvement and is the greatest way to bring about changes in families with the goal of promoting flexibility among family members.
2. A goal of therapy is to help family members open up and more fully be themselves by freely expressing what they are thinking and feeling.
3. The therapist conducts a family therapy session with the intent of it being a growth experience for him/herself, thereby inspiring the family to do the same; therefore, the therapist helps family members focus on the here and now by the therapist “being with” the family.
4. Focus on expanding immediate personal experiences and increasing the family’s awareness by achieving a higher level of intimacy.
5. Unmask pretense, create new meaning, and liberate family members to be themselves.
6. Aim for authenticity as there is no right or wrong way to be.
7. Attempt to unmask and tap into family secrets.
8. Guide the family through three specific phases: engagement (the most powerful), involvement (dominant parent figure, adviser) & disentanglement (more personal, less involved).

E) What Techniques And Skills Are Used?

1. Whitaker pioneered the use of co-therapists as a way to maintain objectivity.
2. Incorporates highly provocative techniques/interventions intended to create turmoil, turn up the emotional temperature, and intensify what is going on here and now in the family while then coaching the family how to get out of the turmoil.
3. Believed in doing therapy with a “crowd” in the room.
4. The therapist is active and directive to help create an intensified affective encounter for family members which allows for the family’s own healing and self-actualizing processes to take hold.
5. Therapist takes a theoretical stance as a way to intensify what the family members are presently experiencing and encourage them to reach into their unconscious to understand what is really going on in the family.
6. Facilitation of individual autonomy and a sense of belonging in the family.
7. Encourage spontaneity, creativity, the ability to play, and the willingness to be “crazy”.
8. The therapist's role is more of a facilitator. Through the use of reflection, he/she exposes the process of family interaction while joining the family process as a genuine and non-defensive person.

F) What Are The Limitations On Those Skills Or Techniques?

1. A great limitation is that this approach de-emphasizes theory and the use of “one-size, fits all” techniques.
2. Therapy follows a subjective focus and centers around the subjective needs of the family members (leaving room for bias or skewed perceptions).
3. This approach relies on a highly involved therapist model where the therapist must be visible, take risks, and get involved with family in the sessions.
4. Since success depends on the collaboration of several people, drop-out rates are high.

G) What Are The Professional Implications?

1. Whitaker typically relied on his own personality and wisdom, rather than any fixed therapeutic techniques to stir things up in families, so it is a hard theory to “teach” in terms of technique.
2. Whitaker believed in a confrontative approach which may not work well with fragile families.
3. This method incorporates an intuitive form of therapy which lower-functioning families/family members may not grasp.
4. He also acquired the reputation as the most disrespectful among family theorists since he often attacked or sought to overthrow traditional or popular ideas in family theory.
5. Some families may not appreciate the unrestrictive, intuitive, non-interventionist, and sometimes outrageous nature of this approach.
6. Rather than focusing on alleviating symptoms, this approach focuses on enhancing the quality of life of the family members. Although some focus on changing the family system may develop, it is not the primary goal. Therefore, this method may not be well suited for families who are looking for crisis management.

Family Therapy for Couples

2007-07-31T16:13:00.000-04:00

■ Behavioral couples therapy has been the most researched.
o Attempts to reduce substance abuse directly and through restructuring the dysfunctional couple interactions that frequently help sustain it

■ Integrative Couples therapy addresses some of the limitations of behavioral couples therapy.
o Helps couples to make arguments less harmful by teaching partners accept their differences.
o Therapy based on the importance of how a couple fights, not whether they fight or not.

■ Insight Oriented couples therapy and emotionally focused couples therapy have also been subjected to clinical trail investigations and found to be superior to no treatment.
o Is a combination of behavioral therapy and helping couples understand power struggles, defense mechanisms, and other negative behaviors.

■ Emotionally focused couples therapy maintains that relationship difficulties stem from the disowning of feelings and attachment needs, creating negative Interactional cycles and ineffective communication patterns.
o It has shown greater efficacy than no-treatment await-list controls.
o Enables couples to identify and break free of their destructive emotional cycles such as when one person criticizes and the other withdraws.
o The therapy helps couples build trust in each other.

■ Evidence for the use of Strategic therapy techniques in the context of couples therapy found an integrated systemic therapy model was equally effective as emotionally focused couples therapy and more effective than await-list control in alleviating relationship distress and improving target complaints and conflict resolutions.

Individually based theory and therapy models 01

2007-07-17T10:42:00.000-04:00

Psychoanalysis- Freud/Erikson/Mahler

Role of Therapist

■ Invisible- Blank Screen (detachment)
■ Fosters transference
■ Focus on Resistance

Therapeutic Goals

■ Bringing the unconscious to the conscious
■ Strengthen the ego

Key Ideas

■ Deterministic- problems are rooted in the first six years of life and trapped in unconscious motivations
■ Reality Principle- maximize gratification minimize punishment
■ Biological Drives- sex and instincts
■ Parts of Personality- Id/Ego/Superego
■ Id- Pleasure principle, “Demanding Child,” deterministic, unconscious, satisfy basic survival
■ Ego- Reality principle, “Traffic Cop,” mediator between Id and Superego
■ Superego- Moral Principle, “The Judge,” strive for perfection

Psychosexual Stages of Development

■ Oral Phase- 0-1 years, greedy, mistrust, unable to form intimate relationships
■ Anal Phase- 1-3 years, anal retentive, aggressive
■ Phallic Phase- 3-6 years, identity disturbance (Oedipal/ Electra complex)
■ Latency- 6-12 years, Socialization stage
■ Genital- 12+, Interpersonal relations freedom to love/work

Techniques

■ Brief psychodynamic therapy (BPT)- treating selective disorders within an established time.
■ Hypnosis
■ Dream Interpretation
■ Free Association
■ Projective Techniques
■ Freudian Slips

Effect of substance abuse & dependence on individual and family functioning

2007-06-20T11:42:00.000-04:00

⋄ Chronic substance abusers tend to be isolated from their families after a long period of damaging relationships.
⋄ Substance abuse affects more than the immediate family.
⋄ Extended family members often report feeling abandoned, embarrassed by, ashamed of, and withdrawn from the substance abusing family member, often choosing to break relational ties.
⋄ Different family structures in which abuse affects the family relationship:
        o Client who lives alone or with a partner.
⋄ Both partners need treatment.
⋄ Groups are offered both for addicts and for non-addict partners of addicts.
⋄ The treatment of either partner will affect both.
⋄ Often, codependence is an issue.
⋄ Enabling may have to be explored
        o Client who lives with a spouse (or partner) and minor children.
⋄ Parental substance abuse has a detrimental affect on children.
⋄ There may be triangulation or enmeshment issues if children are either placed in the middle or if non-using parent is overly protective and bonded with children due to the substance abuser’s lack of responsibility.
⋄ Issues of neglect or trauma may be present if both parents are abusing drugs.
        o Client who is part of a blended family.
⋄ Substance abuse can intensify already shaky ground of newly blended families and become an impediment to integration and stability.
        o An older client who has grown children.
⋄ As with child abuse and neglect, elder maltreatment can be subject to statutory reporting requirements for local authorities.
        o Client is an adolescent and lives with family of origin.
⋄ Non-using children may find themselves neglected or ignored emotionally due to the focus of parents on the using child.
⋄ Often, at least one of the parents uses as well..
        o Someone not identified as the client is abusing substances.
⋄ Issues of blame, responsibility, and causation will arise.
⋄ Scapegoating may be an issue.
⋄ Therapist must work towards uncovering the underlying motivations for substance abuse and other behavioral issues that bring the family into counseling.

Reference materials regarding medication side effects and classification

2007-06-20T11:37:00.000-04:00

AllPsych Online

http://allpsych.com/meds.html

⋄ One of the largest psychology websites on the Internet.
⋄ Holds over 920 individual, cross referenced, web pages and an estimated 3000 pages of printed material.
⋄ It is referenced by over 100 colleges and universities in ten countries.
⋄ It provides:
        o Drug name
        o How they work
        o What they treat
        o Possible side effects

SEDBASE

http://library.dialog.com/bluesheets/html/bl0070.html

⋄ This is a full text database that critically analyzes the published drug side effect literature on drugs currently in use.
⋄ Drug class chapters are prepared by recognized authorities who critically assess published literature each year.
⋄ The goal of the database is to document every drug known to have a side effect reported in the literature.
⋄ It is organized by drug class chapters and does not contain any speculative or unsubstantiated statements.
⋄ Some of the specific areas covered include:
        o adverse drug reactions
        o drug interactions
        o drug toxicity
        o special risk situations
        o pharmacological or patient-dependent factors associated with the occurrence of side effects.

Managing Transference and Countertransference

2007-06-20T11:30:00.000-04:00

Transference

⋄ Feelings client projects onto the counselor.
⋄ Have to do with relationship client has experienced in the past.
⋄ Intensity of feelings has to do with unfinished elements of client’s life.
⋄ Client may identify in the therapist characteristics that are reminiscent of the person they are transferring their emotions from.
⋄ Feelings can be productively explored so client becomes aware of how they are keeping an old pattern functional in other present time relationships.
⋄ Therapy becomes an ideal place to become enlightened to patterns in relationship of psychological vulnerability.
⋄ Clients gain insight into how their unresolved issues lead to dysfunctional behavior.
⋄ Group therapy may provide a microcosm of how people function in general social settings.
⋄ Ask client to tell more about how the therapist has affected them to elicit additional information about how the client developed the transference.
⋄ Do not become defensive.
⋄ “I wonder if I remind you of anyone you have had similar feelings with?”
⋄ There is potential for rich therapeutic progress!
⋄ Carefully take on a symbolic role and allow the client to work through their unresolved conflict.

Counter-transference

⋄ Feelings aroused in the counselor by the client.
⋄ Feelings have to do with unresolved conflict from other past or present relationships rather than the therapeutic relationship with this particular client.
⋄ Discuss how you are affected by certain clients in supervision on with a colleague.
⋄ Get other’s perspectives on whether you are maintaining unconditional positive regard.
⋄ Self-knowledge is the basic tool in dealing with Counter-transference.
⋄ Unacknowledged, this can lead to an unproductive group. If leaders are not willing to deal with their own issues, how can they expect clients to do so?
⋄ Counter-transference in groups can be indicated by exaggerated and persistent feelings that tend to recur with various clients of different groups.

Crisis Intervention Models

2007-06-20T11:19:00.000-04:00

Crisis intervention with date rape, school violence, substance abuse, adolescent suicide, marital abuse, HIV positive, and hospital intensive care clients.

Step #1: Listen
- Establish therapeutic relationship.
- Identify precipitating problems.
- Explore emotions.

Step #2: Assessment
- Determine the severity of the crisis.
- Assess potential lethality or physical harm to the person or others.
- Identify past coping skills, strengths and supportive resources.
- Suicide/Homicide assessment
- Determine client’s perception of reality.
- Discuss cultural beliefs about handling trauma.
- Find out if family and social resources are potential resources. Are the resources positive or negative?

Step #3: Treatment Plan
- Selectively choose and use appropriate approaches to action planning.
- Modify or eliminate past coping skills.
- Create a contract or have client sign treatment plan.
- Identify useful referral resources.
- Use three basic approaches:
        i. Start by being non-directive.
        ii. Be collaborative by working together on a joint plan.
        iii. Be directive if the person does not or will not make a plan.
- During crisis, have only short term objectives.

Step #4: Termination
- Review progress on treatment plan.
- Plan for expanding resources and support system.
- Schedule a follow up session.

Risk factors and relational patterns of endangerment

2007-06-20T11:10:00.000-04:00

Risk factors for Victimization

o Being female
o Young age
o Being a minority
o Drug and alcohol use
o High-risk sexual behavior
o Exposure to victimization as a child
o Low education level
o Unemployment
o Low SES
o Little or no support system
o Low self esteem
o Adolescence or developmental transition period
o Having a verbally abusive, jealous, or possessive partner
o Couples with income, educational, or job status disparities
o Dominance and control of the relationship by the male
o Weak community sanctions against victimization (e.g., police unwilling to intervene)
o Traditional gender norms (e.g., women should stay at home and not enter workforce, should be submissive)

Risk Factors for Perpetration

o Low self-esteem
o Low income
o Low academic achievement
o History of delinquency in youth
o Drug and alcohol use and abuse
o Depression or other psychological diagnosis
o Anger management issues
o Axis II disorders
o Past history of abuse
o Social isolation
o Unemployment
o Emotional dependence or codependence
o Belief in strict gender roles
o Abuse of power and control
o Past history of victimization
o Marital conflictfights, tension, and other struggles
o Marital instabilitydivorces and separations
o Unhealthy family enmeshment or blurred boundaries

DSM and ICD Health Problems

2007-06-11T12:08:00.000-04:00

Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Statistical Classification of Diseases & Related Health Problems (ICD)

Diagnostic and Statistical Manual of Mental Disorders (DSM)

o Handbook for mental health professionals.
o Includes all categories of mental disorders and their corresponding diagnosable criteria.
o Intended to be used by those with clinical training.
o In accordance with the American Psychiatric Association.
o Uniform criteria for diagnosing.
o Includes sociological, psychological, biological, criteria.
o Each revision has discarded some previously diagnosable disorders such as pre-menstrual dysphoric disorder and masochistic personality disorder to show the manual is contemporary with social times.
o It now no longer includes homosexuality as a mental disorder, replacing it with sexual orientation disturbance, though still controversial.

Diagnosing Categories

o Axis I: Clinical disorders, including major mental disorders, as well as developmental and learning disorders
o Axis II: Underlying pervasive or personality conditions, as well as mental retardation
o Axis III: Acute medical conditions and Physical disorders.
o Axis IV: Psychosocial and environmental factors contributing to the disorder
o Axis V: Global Assessment of Functioning GAF score
o A scale from 100 (good functioning) to 0 (several dysfunction)

International Statistical Classification of Diseases and Related Health Problems

o Abbreviation ICD.
o Classification system for diseases including a directory of symptoms complaints, and external causes of injury or illness.
o Published by the World Health Organization.
o Used by hospitals and healthcare facilities to best describe clinical assessment of a client.

Diagnostic interviewing techniques

2007-06-06T10:26:00.000-04:00

Questioning:
o Client asked direct questions in areas determined by interviewer
o Questioning may be open or closed.
Open= unlimited answer options
Closed= Yes, No, or one word questions

Reflection:
o Restate the clients cognitive or emotional material
o Demonstrate empathic understanding
o Rogerian Client-Centered Therapists rely heavily on reflection
o Overuse is counterproductive - important areas are left unaddressed

Restatement (Paraphrasing):
o Rephrase what client says.
o Demonstrates active listening.
o Reflection is type of intervention, clarifies and joins themes.

Clarification:
o Accompanied by utilizing other techniques such as questioning, paraphrasing, restating
o Shows understanding of client in the interview
o If done from a not knowing stance, should not invoke defensive response.

Confrontation:
o May be used to call client out on discrepancies
o Is often used with substance abusers in order to break denial and/or rigid defenses
o This may increase anxiety and avoidance but is necessary and can be constructive.

Self-disclosure
o The sharing of personal experiences by the therapist to the client relative to the session with the purpose of helping.
o Intended to facilitate client disclosure.
o Should be used minimally
o Must be careful not to cross boundaries.

Silence:
o While this may occur unintentionally there are many benefits if used correctly.
o Provides both client and therapist time to process what is being understood.
o Timing is essential
o Promotes introspection

Exploration:
o Therapist test the limits of what client is willing to process.
o May be used to determine clients level of insight.

Reframing (Cognitive reframing):
o This allows for a different perspective
o Used to challenge negative self concepts and harmful thinking patterns.
o The purpose is to lead to behavioral change.

Family Life Cycle Stages

2007-06-06T10:13:00.000-04:00

Stages

1. Married Couples without children
2. Child bearing families
3. Families with pre-school children
4. Families with school children
5. Families with teenagers
6. Families launching young adults
7. Middle aged parents- empty nest to retirement
8. Aging Family members- retirement to death of both spouses

Family Stage impact on Problems

Vertical Stressors
o Relational patterns that are transmitted from one generation to another
o Family attitudes
o Secrets
o Taboos
o Hopes
o Failures
o Expectations
o Emotional Struggles

Horizontal stressors include predictable events that occur as families move from one life cycle stage to another.
o Birth of a child
o Parenting adolescent children
o Children leaving home
o Death of a parent
o Menopause
o Health concerns
o Changes in self image
o Career shifts
o Infidelity
o Infertility

Statutes, case law and regulations

2007-06-04T10:20:00.000-04:00

Professional disclosure statement tells clients about:
o the education and qualifications of the therapist
o the nature of the therapeutic process
o Informed Consent
o Document that the client reads about the specifics of therapy treatment
o Client consents to treatment by signing the form
o Procedures and goals of therapy
o Potential harms or risks to client
o Reasonable benefits of therapy
o Qualifications and policies of therapist
o Theoretical orientation of therapist
o Ability to terminate treatment at any time
o Reassurance of referral sources for treatment (3 is standard)
o Fee disclosure

Confidentiality
o Ethical obligation of therapist to keep communications between themselves and client private.
o May be charged in contempt of court if therapist refuses to testify about a client.

Exceptions:
o Child abuse reporting laws: mandated to report the suspicion of child abuse or neglect. (in some states this is required of all citizens not just counselors)
o Duty to warn: if therapist establishes there is a likelihood that client will cause harm to him/herself or to someone else and the therapist knows who that victim may be.

Privilege- Legal right, owned by the client, which is an exception to the general rule that the public has a right to relevant knowledge in court proceedings. This means information revealed in session is not permitted in court.

Appropriate standard of care- how most therapists would treat a case under similar circumstances. Those who do not follow this are at risk for malpractice.

Dual relationship- occur when therapist does not keep appropriate boundaries and thereby blends personal or business relationships with the therapeutic relationship.

Secret policies- written statements about how information shared privately will be handled by the therapist. Must be signed by both parties.

Risk factors for and patterns of abuse

2007-06-04T10:17:00.000-04:00

Recognizing sings of abuse

In the child:
o Sudden changes in behavior or school performance
o Not medical attention for problems brought to parents attention.
o Learning problems, difficulty concentrating, that cannot be attributed to specific disabilities.
o Tends to be watchful, expecting something to happen.
o Lacks adult supervision.
o Overly compliant, passive, or withdrawn.
o Comes to school or other activities early, stays late, does not want to go home.

The Parent:
o Shows little concern.
o Denise existence of, or blames the child, for problems at school or home.
o Asks teachers to use physical discipline.
o Describes child as bad or burdensome.
o Demanding high levels of academic and physical performance.
o Relies on child for care, attention, emotional needs.

Parent and Child:
o Do not look or touch each other.
o View of relationship is only negative.
o State they do not like each other.

Pattern of Abuse

Tension building
o Anger builds.
o Poor communication.
o Victim feels the need to keep the abuser calm.
o Tension mounts.
o Victim constantly feels weary of abuser.
o Abuse (physical, emotional, or sexual) takes place.
Making up:
o Apology may be made.
o Promise of the last time.
o Victim blaming.
o Denial of abuse.
o Calm
o Abuser acts as if nothing has happened.
o Some promises may be met, during this time.
o Victim may believe the abuse is truly over.
o Abuser may give gifts to victim.

Integrative Couples Therapy

2007-06-04T10:10:00.000-04:00

History

1969 Richard Stuart introduced behavioral elements into couples therapy.
1970s couples therapy was based on behavioral change.
As couples theories evolved, behavior and adjustment techniques used to adjust social skills were introduced.
1980s communication skills became and integral part of the healthy functioning couple
Couples therapy began to incorporate family intervention elements in addition to behavioral elements and communication skills building.
1993 Jacobsen and Anderson founded the Integrative Couples Therapy Model.

Theoretical Foundations

Eclecticism
o A mix of different counseling methods
o More freedom because not limited to one theoretical view.
Theories commonly used:
o Problem-focused
o Narrative
o Brief/Solution-focused
o Cognitive Behavioral
o Bowen Family Systems Theory

Core Premise

Circular Model of Causation
o The foundation of Integrative Therapy is the idea of a circular process of assessment, goal setting, interventions, maintenance, and validation.
o It is a non-linear model
o Any one of these concepts can be revised throughout the session at any given point.
The focus is to create a blame free therapeutic environment.
Integrative Therapy emphasizes that the couple work together to overcome their difficulties giving them a common goal.

Codes of ethics

2007-06-01T13:12:00.000-04:00

Ethics= the study of what constitute s good and bad human conduct, including related actions and values. Ethical practice by a therapist is when a therapist has good moral sense, follows the code of ethics, is up to date on the existing laws that impact their clients, and have good clinical expertise.

Professional code of ethics functions
Define the role of the profession
o Codes express dominant morality of the field
o Define values and goals of the profession.
o Define the standards that both the professionals and users of the professionals services can expect in professional interactions.
Ethical codes guide the conduct of profession and can provide specific guidance about conduct in form of advice or mandates.

Moral Foundations
Autonomy- people are allowed the freedom of choice and action.
Nonmaleficence- above all else, therapist will do no harm.
Justice- humans should be treated fairly with equal distribution of good or bad.
Fidelity- value of honoring commitments and promoting trust.
Veracity- importance of truth telling
Beneficence- refers to promoting good.

Malpractice claims- legal actions taken against therapist for actions that are believed to fall below the appropriate standard of care and cause injury to client

Common types of malpractice include:
Misdiagnosis
Practicing outside area of competence.
Failure to obtain informed consent treatment
Negligent or improper treatment
Physical contact or sexual relationships with patient
Failure to prevent patient from harming themselves or others
Improper release of hospitalized patients
Failure to consult another practitioner or refer a patient
Failure to supervise students/interns
Abandonment of patients

Emotional Focused Couples Therapy 01

2007-05-31T14:15:00.000-04:00

Introduction

Emotion is the music of the dance between partners, learn to change the music and change the dance.

What is EFT?

• EFT expands experience and interactions.

• It is the accessing and reprocessing of emotional response underlying partner’s interactional position. The reprocessing of inner experience is used to expand the interpersonal context. In turn the structuring of new interactional events expands and redefines each partner’s inner experience.

• It facilitates a shift in positions towards accessibility and responsiveness- which are the building blocks of secure bonds.

• It creates new interactional events that redefine the relationship as a source of security and comfort for each of the partners.

• When EFT is successfully implemented, each partner experiences the other as a source of security, protection, ad comfort.

• Each partner can then assist the other in regulating negative affect and constructing a positive and potent sense of self.

EFT Structure

• Step 1: Assessment- Create an alliance and delineate conflict issues in the core struggle

• Step 2: Identify negative interactional cycle.

• Step 3: Access unacknowledged emotions underlying interactional positions.

• Step 4: Reframe the problem in terms of underlying emotions and attachment needs.

• Step 5: Promote identification with disowned needs and aspects of self and integrate these into relationship interactions.

• Step 6: Promote acceptance of the partners experience and new interaction patters.

• Step 7: Facilitate the expression of needs and wants and create emotional engagement.

• Step 8: Facilitate the emergence of new solutions to old relationship problems.

• Step 9: Consolidate new positions and new cycles of attachment behaviors.

Foundations of Marital and Family Therapy

1940

Theodore Lidz

Study of families of schizophrenics

Introduced concepts of

Schism= division of family into two antagonistic and competing groups.

Skew= one partner in marriage dominates the family as a result of serious personality disorder in one of the partners.

1950

Nathan Ackerman

The Psychodynamics of Family Life

Began treating client mental disorders through family process dynamics.

Gregory Bateson

Formulated controversial yet influential theory of dysfunctional communication called the double-bind.

Two seemingly contradictory messages may exist on different levels and lead to confusion or schizophrenic behavior on the part of the individuals receiving those messages.

Milton Erickson

Established Brief Therapy

Carl Whitaker

Risked violating the conventions of traditional psychotherapy

Published work in dual therapy or conjoint couple therapy.

Murray Bowen

Began holding therapy sessions with all family members present as part of a research project on schizophrenics.

Elaborated theory on the influence of previous generations on mental health of families.

Emotional Reactivity

Found that when troubled families were brought together they had difficulty maintaining their identities

Described this as an undifferentiated family ego mass

Worked to help them establish appropriate relationship boundaries and avoid projecting or triangulating.

1960s

Jay Hayley

Began to formulate Strategic Family Therapy.

Emphasis on gaining and maintaining power during treatment.

Edited Family Process, first journal in field of family therapy.

Salvador Minuchin

Used his own form of family therapy with urban slum families

Reduced recidivism rate for delinquents in school.

Training local members of the black community as paraprofessional family therapists.

Cultural differences often makes it difficult for white middle class therapists to relate successfully to urban black and Hispanics.

Virginia Satir

Social work background

Gained prominence in Mental Research Institute

Unique in being only woman pioneer of family therapy.

Focused on importance of self esteem, compassion, and congruent expression of feelings.

John Bell

Started using group therapy as a basis for working with families

Structural program of treatment that conceptualized family members as strangers.

1970s

R.D. Laing

Coined the term mystification

Describes how some families mask what is going on between family members by giving conflict and contradictory explanations of events.

Rachel Hare-Mustin

Feminist Approach to Family Therapy

Goal of working with a families

Facilitate the growth of a strong woman who have enhanced control over resources

Increase the ability of women to work together politically to make societal changes.

1980s

Women came to forefront

Monica McGoldrick

Carolyn Attneave

Peggy Papp

Peggy Penn

Cloe Madanes

Fromma Walsh

Betty Carter

1990s

Steve deShazer

Narrative theory

Bill OHanlon

Solution Focused

General Systems Theory

2007-05-31T10:51:00.000-04:00

Developed by Ludwig von Bertalanffy in 1968.
Explains how organisms thrive or die in accordance with their openness or closedness to their environments.
Focus changed from linear causality to circular causality- idea that events are related through a series of interacting loops or repeating cycles.

System
Set of elements standing in interaction.
Each element is affected by whatever happens to any other element.
System is only as strong as its weakest part.
System is greater than sum of its parts.
Boundaries are more or less permeable depending on the amount and type of feedback received.

Divorce

2007-05-29T15:40:00.000-04:00

The diagnosis typically assigned for clients and families dealing with divorce is depression. The symptoms are usually the same for children, adolescents, and adults.

Symptoms:
•        Persistent sadness
•        Inability to enjoy favorite activities
•        Increased irritability
•        Physical problems such as headaches and stomach aches
•        Poor school performance
•        Poor work performance
•        Persistent boredom
•        Low energy
•        Poor concentration
•        Changes in eating and or sleeping patterns

Long-term Treatment Goals for Treating Depression due to Divorce
•        Improved mood and stability
•        Prevent further episodes of depression
•        Help the client become well established in a new family living arrangement

Short Term Objectives
•        Develop therapeutic rapport
•        Identify feelings and anxieties about divorce
•        Increase social contacts and create a support system
•        Develop coping skills to deal with depressive thoughts and feelings
•        Discuss the feelings about the loss of the family relationship is it was
•        Help client adapt to new situation

Interventions
•        Verbal therapy to discuss feelings
•        Play/ Art therapy:
        o        Pairing emotions and colors
        o        Draw different representations of emotions symbolically
        o        Use clay or other materials to recreate story
        o        Puppets to tell a story
        o        Board games designed to discuss feelings
•        Writing:
        o        List positive and negative emotions or changes
        o        Journal feelings
        o        Unsent letters
•        Parent Education
        o        Teach parents about typical emotional reactions they will see in their children and how to handle them.
        o        Encourage parents to make teachers aware of the situation.
        o        Have parents engage in an activity with the children each week, teach dyadic techniques.

Infertility- inability to conceive during one year of sexual intercourse without the use of contraception, or the inability to carry a pregnancy to live birth.

There are two kinds of infertility diagnoses:
•        Primary infertility - couples who have never had a child
•        Secondary infertility - couples who are unable to conceive or to achieve a live birth after having previous children.

Male infertility
•        Lifestyle habits can markedly affect the quality of the semen.
        o        Alcohol can damage sperm-producing tissue.
        o        Tobacco decreases sperm survival and function.
        o        Diet and vitamins have been researched to affect sperm production.
        o        Sexual practices can be altered to increase fertility.
•        Abstinence periods of three to four days produce larger semen quantities and greater viability.
•        Certain common lubricants such as KY jelly, lotions, and oils can kill sperm and decrease fertility.

Female Infertility
•        Can often lead to profound distress for women and may affect sexual functioning in couple’s relationship and is associated with a wide range of factors:
        o        Physical- hormonal, anatomical, genetic, immune system
        o        Psychological- denial, grief, helplessness, anger, anxiety, and guilt
        o        Environmental- work related stress, family issues, gender role expectations.

Goals of Therapy
•        Explore their beliefs about creating a family
•        Identify and explore feelings and reactions to infertility
•        Create a support system
•        Provide educational materials related to medical procedures
•        Assist partners in communication about sexual relationship

Sexual abuse treatment for victims, perpetrators, and their families

2007-05-25T23:39:00.000-04:00

Sexual assault is a traumatic event from which many victims never fully recover. Victims often develop problems with post traumatic stress disorder (PTSD), depression, poor self-esteem, interpersonal difficulties, and sexual disorders. PTSD is overwhelmingly the most common disorder related to sexual abuse.

Children may have some symptoms that are different from adults such as agitated behavior, repetitive play involving trauma, frightening non-specific dreams, and reenactment of the traumatic event.

Long Term Treatment Goals
•        Ensure safety from further victimization.
•        Help client understand and control the feelings and behavior that accompany the assault.
•        Build self esteem.

Short Term Treatment Goals
•        Establish therapeutic rapport and open communication with client.
•        Assess the level of symptomology.
•        Obtain medical assistance (forensic examination).
•        Obey child abuse laws (mandatory reporting)
•        Assess for suicidal tendencies.
•        Have client tell their story.
•        Identify and express feelings about the abuse.
•        Decrease feelings of guilt and shame.
•        Increase feelings of empowerment.

Therapeutic Interventions
•        Write out what happened including feelings.
•        Play Therapy
        o        Angry tower: build tower, then verbalize while throwing things at the tower, watching it topple, to allow feelings to emerge.
•        Mutual Story telling
        o        Client and therapist take turns telling stories (may use puppets dolls or stuffed animals).
•        Art Therapy
        o        Associate color with feelings
        o        Draw different scenes for different feelings
•        Letter
        o        Have client write letter to perpetrator that describes feelings about the abuse. Process the letter.
•        Develop personalized Safety Plan
        o        Self defense classes
        o        Safety escape routes.
        o        Who to call in cases of emergency
        o        Domestic violence safety plans can be searched for online.
•        Challenging Beliefs
        o        Discuss myths and realities
        o        Reduce feelings of shame and guilt
•        Encourage group work

Family Interventions
•        Encourage parents to reassure child that they are not angry at family member/victim.
•        The best things parents can do is believe the client.
•        Encourage the whole family to find support, as well as being a support for each other.
•        Establish safety for the whole family.
•        Have parents request and advocate.
•        Encourage the family to make sure client knows they are not to blame.
•        Discuss myths as a family.
•        Tell families to make sure they take care of themselves too during this difficult time.

Non-standardized Assessment Tests

2007-05-24T00:04:00.000-04:00

Genograms

*        First developed and popularized in clinical settings by Monica McGoldrick and Randy Gerson.
*        Developed principally within the context of Murray Bowen’s intergenerational family systems theory, genograms offer an efficient and effective process for explaining repetitive behaviors and patterns.
*        Essentially, genograms are graphic representations of an individual’s extended family that typically cross at least three generations.
*        Use of genograms implies a respect for intergenerational family experiences as historical antecedents to contemporary areas of strength and difficulty.
*        Most genograms include basic information about number of families, number of children in each family, birth order, and deaths. Some genograms include information on disorders running in the family such as alcoholism, depression, diseases, alliances, and living situations.
*        Genograms reflect an individual’s point of view. Although most members of a family agree on the basics of a family tree, there may be major differences when describing the relationships among family members.
*        Interpretation is influenced by the creator of the Genogram. There is no absolute “right” Genogram for one family. Different family members may have differing perspectives on the relationships in the family and may therefore construct genograms of the same family very differently.

Scaling Questions

*        Used primarily in Solution Focused Brief Therapy.
*        Used to track differences and progress in the client.
*        Helpful in prioritizing goals.
*        Ranges of a scale can be defined in each time a question is made.
*        Typically range from worst (zero) to the best (ten).
*        Client may rate same question repeatedly as therapy progresses.
*        Client may be asked to identify times when the client felt lower on the scale.
*        Establishing goals or generating solutions comes from having the client identify what a higher score will look like for them and what they need to get there.
*        Strength focused questions include “What have to done to get to this (higher) score?” “What has stopped you from slipping one point lower down the scale?"
*        Exception questions include “Have you ever been higher on the scale?” “What is different on the days when you are one point higher on the scale?” “How would tell you that it was a 'one point higher' day?"
*        Future focus questions include “Where on the scale would be good enough for you?” “What would a day at that point on the scale look like?"

Dimensions of Sexual Experience

*        Trance State
        o        Akin to sensate-focus activities.
        o        Introspective attention to one’s kinesthetic cues of arousal.
        o        Individual becomes absorbed in sex.

*        Role Enactment
        o        Playing out roles of sexual fantasies and/or scripts
        o        Successful role enactment is indicated by in-depth integration with role during sex.
        o        Minimal involvement is indicated by avoidance, disinterest, or “faking it”

*        Partner Engagement
        o        Profound personal meaning is found in the sexual involvement with the partner
        o        Ranges from appreciation to sense of mystical union.
        o        Characterized by a unique, loving bond.

Power Hierarchies- on being Needed and Wanted

*        Wanting to be wanted- the individual searches for a reflected sense of self
*        Not wanting to want- attempt to maintaining boundaries to protect the ego.
*        Wanting to be wanted and gratified by not wanting to reciprocate- the individual is insecure about being exploited or abandoned and develops a narcissistic demand to be unilaterally gratified.
*        Not wanting to be wanted- the individual avoids any reciprocity.

These power hierarchies develop in response to differentiation and object relations issues from childhood in family-of-origin. Marriage devises the opportunity to resolve family-of-origin issues and individual long term development/existential conflicts.

Genograms

*        First developed and popularized in clinical settings by Monica McGoldrick and Randy Gerson.
*        Developed principally within the context of Murray Bowen’s intergenerational family systems theory, genograms offer an efficient and effective process for explaining repetitive behaviors and patterns.
*        Essentially, genograms are graphic representations of an individual’s extended family that typically cross at least three generations.
*        Use of genograms implies a respect for intergenerational family experiences as historical antecedents to contemporary areas of strength and difficulty.
*        Most genograms include basic information about number of families, number of children in each family, birth order, and deaths. Some genograms include information on disorders running in the family such as alcoholism, depression, diseases, alliances, and living situations.
*        Genograms reflect an individual’s point of view. Although most members of a family agree on the basics of a family tree, there may be major differences when describing the relationships among family members.
*        Interpretation is influenced by the creator of the Genogram. There is no absolute “right” Genogram for one family. Different family members may have differing perspectives on the relationships in the family and may therefore construct genograms of the same family very differently.

Scaling Questions

*        Used primarily in Solution Focused Brief Therapy.
*        Used to track differences and progress in the client.
*        Helpful in prioritizing goals.
*        Ranges of a scale can be defined in each time a question is made.
*        Typically range from worst (zero) to the best (ten).
*        Client may rate same question repeatedly as therapy progresses.
*        Client may be asked to identify times when the client felt lower on the scale.
*        Establishing goals or generating solutions comes from having the client identify what a higher score will look like for them and what they need to get there.
*        Strength focused questions include “What have to done to get to this (higher) score?” “What has stopped you from slipping one point lower down the scale?"
*        Exception questions include “Have you ever been higher on the scale?” “What is different on the days when you are one point higher on the scale?” “How would tell you that it was a 'one point higher' day?"
*        Future focus questions include “Where on the scale would be good enough for you?” “What would a day at that point on the scale look like?"

Risk factors, stages and patterns of grief response

2007-05-23T23:59:00.000-04:00

•        DSM Diagnosis under Other Conditions That May be Focus of Clinical Attention, V62.82, Bereavement- used for death of a loved one.
•        Depression in this case is considered “normal” but individual my be seeking treatment to relieve symptoms such as insomnia or anorexia.
•        Expression of “normal” bereavement time is relative to different cultures.
•        Major Depressive disorder is not diagnosed unless symptoms last longer than two months after loss.

Stages of Grief:
•        Denial
•        Anger
•        Bargaining
•        Depression
•        Acceptance

Reactions commonly seen in children:
        o        Disbelief- children may act as if it did not happen.
        o        Complain of headaches, stomachaches, or fear of their own death.
        o        Anger- concern over own needs and about being alone, or with God.
        o        Guilt- feelings of causing death, or not having been “better”
        o        Anxiety/Fear: may become clingy and need validation of love.
        o        Regression: revert to bed wetting or thumb sucking
        o        Sadness: lethargy and isolation

Short Term Treatment Goals
•        Express fear and anger, grieve in a healthy way.
•        Loss and Grief Counseling Group
•        Recall fond memories
•        Create a phone list of supportive people to call
•        New coping techniques
•        Find a “safe place” to spend limited time thinking about deceased
•        Exercise regiment
•        Relaxation techniques- progressive muscle relaxation, guided imagery

Long Term Treatment Goals
•        Reach a point of coping without being overcome with grief.
•        Regain normal activity.
•        Reduce feelings of guilt and anger towards self, others, and God.
•        Re-mature over regressed behaviors
•        Understanding of death and life.

Therapeutic Interventions
•        Writing Activities
        o        Letter to deceased for closure
        o        Journal of thoughts (may be shared in counseling, in group, or with family members)
•        Art therapy:
        o        Finger paints are useful in expressing feelings
        o        Draw pictures of activities enjoyed with deceased (useful with children).
        o        Collage on a theme
        o        Splatter room: area where (particularly children) are free to throw violent splotches of paint to get anger out.
•        Play Therapy:
        o        Model clay or dough to vent anger or create ritual objects
        o        Puppetry- to express feelings
        o        Sand tray to play out themes, “burry” deceased for closure, or rake sand for relaxation or meditation.
•        Bibliotherapy:
        o        Appropriate self help books
        o        Books related to symptoms client is displaying
•        Loss Graph or Timeline:
        o        Used to discuss types of loss
        o        Used to recall fond memories and celebrate life
•        Storytelling:
        o        Fantasy monologues
        o        Mutual storytelling
•        Therapeutic Metaphors
        o        Helpful in understanding concept of death
•        Empty Chair
        o        Gestalt technique
        o        Imagine deceased in chair and speak to them for closure