Assignment

Historical Background Psychosocial Diagnostic Assessment

From the birth of the social work profession, many different assessment models have been used. Perhaps the most well-known is the psychoso- cial or diagnosis approach first developed by Hollis. This model relies heavily on family and developmental history to reach a psychodiagnostics assessment of the client. An ego-psychology framework (Goldstein, 2002) is fundamental to this approach. Although this approach initially focused to a large extent on a client’s developmental history, now the person/client in relationship to the current environment is stressed. According to a psychosocial-ego-psychology perspective, the assessment process has the following steps: (a) assessing the client’s interactions with his or her environment in the here and now and how successfully he or she is coping effectively with major life roles and tasks; (b) assessing the client’s adaptive, autonomous, and conflict-free areas of ego functioning as well as ego deficits and maladaptive functioning; (c) evaluating the impact of a client’s past on current functioning; and (d) examining environmental obstacles that impede a client’s functioning (Goldstein, 2002; Hollis & Wood, 1981). According to a psychosocial diagnostic approach, information for client assessment was collected in a variety of ways, including (a) psychiatric interviews to determine a diagnosis, (b) the use of standardized and projective testing to support diagnostic assessment, (c) current psychosocial assessment and study of prior development and adjustment to identify problem areas, (d) use of standardized interviewing to assess problem areas and current functioning, and (e) study of the client-social work relationship to ascertain client’s patterns of interactions (Jordan & Franklin, 2003). The psychosocial assessment model is well suited to today’s medical model that involves the study, diagnosis, and treatment format. Many medically based behavioral-health settings use this approach. Furthermore, the focus of many behavioral-health centers on clients’ return to more adaptive functioning is also compatible with a psychosocial-diagnostic-ego- psychology model. A DSM-IV diagnosis is usually a requirement for beginning treatment, and thus the detailed study using a psychosocial approach is often helpful in arriving at a diagnosis. Structured assessment tools, such as the eco-map (Hartman & Laird, 1983) and the genogram (McGoldrick, Gerson, & Schallenberg, 1999), are also helpful for practitioners in completing assessments. There is a need for more outcome-focused research, however, on the effectiveness of using these instruments. Finally, the development of standardized semi structured interviews using a psychosocial approach is most helpful in promoting current evidence-based assessment.

Problem-Solving Assessment

Another major assessment model was the problem-solving assessment originally developed by Helen Harris Perlman in 1957. This model is based on the psychosocial diagnosis model described earlier and the functional model that focuses on growth and potential as well as agency function. Perlman saw assessment as an eclectic model with four Ps—person, problem, place, and process—as a way to organize information about the client. In terms of person, the social worker should think of the client’s personality characteristics and which interactions with the environment are significant. A second area involves a focus on problem: How can the problem be defined? Is it a crisis, a repetitive issue? What other ways has the client sought to resolve the problem? The third category is place or agency. What concerns does the client have about contact within the agency? What is most helpful and what is most harmful about the agency in the process of client assessment? The fourth relates to process. Which intervention will be most successful? What will be the consequences of a particular choice of treatment?

Current assessment still relies a great deal on the problem-solving approach to assessment. First, a very quick assessment tool, such as that outlined by Perlman, is most helpful in the current social-service environment, with its focus on short-term assessment and intervention. Another advantage, especially for culturally diverse clients who may be fearful of interaction with the agency, is the inclusion of Perlman’s third P—place—in the assessment process. This approach encourages the social worker to look at how the fears and feelings that clients may have about the agency affect the assessment process. This may be especially true for undocumented clients who are apprehensive that social workers will use their power and authority to report their immigration status.

There are two major concerns about the problem-solving approach as used in current assessment practice. First, there is limited attention to the person’s strengths and resilience in resolving the problem. Modern assessment models seek to focus specifically on the strengths a client brings to the situation. The client’s definition of the ‘‘problem’’ and what strengths he or she can use and has used in the past to address the problem are considered key. Another major concern about the problem- solving approach is that it is based primarily on practice wisdom, with limited empirical research to support its use. With the emphasis on EBP, research is needed to ascertain the effectiveness of this assessment model as a foundation for treatment interventions with diverse clients.

Cognitive-Behavior Assessment

Cognitive-behavior assessment models have made a major contribution to current practice and research about assessment. Meichenbaum (1993) out- lines three metaphors that have guided this complex model—conditioning, information processing, and constructive narrative. Early cognitive behaviorists focused primarily on conditioning as the way certain behaviors were learned. Then the focus shifted to a greater emphasis on cognitions, social learning, and the development of belief systems. Most recently, the focus has been on the use of client narratives and life stories as part of the assessment process.

Jordan and Franklin (2003) identify four attributes of cognitive behavior assessment that are particularly useful in today’s practice:

1. Because much of today’s practice focuses on short-term intervention, the focus on rapid assessment and treatment is particularly useful. Assessment includes history only as it is related to the client’s current functioning, but the main focus is on identifying the faulty learning and cognitive patterns that have contributed to current maladaptive behavior.

2. Much research has been conducted on outcomes of cognitive behavior approaches. This is particularly useful with today’s emphasis on evidence-based assessment and treatment.

3. Many assessment and treatment manuals for use with assessing a number of identified client problems, such as depression, substance abuse, personality disorders, and posttraumatic stress disorder, have been developed using the cognitive-behavioral approach.

4. Ongoing assessment has been stressed as essential in evaluating the effectiveness of treatment. The integration of assessment with treatment is very much part of current beliefs about assessment.

Life-Model Assessment

The life-model assessment (Germain & Gitterman, 1996) uses an ecological framework that focuses on the client’s interactions with the environment in three main areas—life transitions, environmental pressures, and mal- adaptive interpersonal processes. Major aims of this theory are too closely link person and environment, stress the client’s perspective, and provide linkages among direct service, administration, and policy planning.

There has been some concern that the life-model assessment does not guide current practice interventions very well (Wakefield, 1996). With the need for short-term evidence-based assessment and intervention, the weakness of this link is problematic. The ecological model, however, has served as a foundation for developing multisystemic therapy, an evidence-based therapy that has proven to be useful with youth and families (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998). An assessment tool, such as the eco-map (Hartman & Laird, 1983) that is based on the life-model ecological approach, has been useful, although research on this has been limited. Computer software programs may help practitioners use this assessment tool more effectively, standardize its use, and provide more opportunities for research about its effectiveness.

Task-Centered Assessment

The task-centered assessment model developed by Reid (1988) focuses on specific target problems and their desired outcomes. Major steps in this model include task planning, implementation, and review. Task planning builds on initial problem formulation. The client’s perception of the problem is considered most important, and the practitioner helps the client in exploring, clarifying, and specifying the problem. Task-centered assessment focuses on a thorough understanding of the client’s problems and goals, prioritizing problems and developing a specific contract to achieve the defined goals. This approach is most useful in practice today with a focus on time-limited and evidence-based outcomes.

Solution-Focused Assessment

A major new assessment model is the brief solution-focused therapy assessment developed by De Jong and Berg (2001) for work with mandated clients. With this model, assessment is part of the intervention process. Franklin and Moore (1999) have identified the following methods for conducting a solution-focused assessment:

· Tracking solution behaviors or exceptions to the problem.

· Scaling the problem.

· Using coping and motivation questions.

· Asking the miracle question.

This approach is very client centered and focuses on client’s strengths—what clients can do and want to do, not on their deficits and failures. Franklin (2002) identifies positive features of this model with mandated clients:

· Using a nonjudgmental approach in understanding client problems.

· Making the congruence between what the client wants and what services can be provided as close as possible.

· Emphasizing clients’ choices as much as possible.

· Providing education to clients about what treatment will involve.

· Developing specific goals with clients.

· Discussing what is nonnegotiable from the agency’s standpoint.

Although research on the use of this model has been positive, more work in this area is necessary to evaluate its effectiveness.

Strengths-Perspective Assessment

A final perspective that has had a major influence on current assessment practice is the strengths perspective developed by Saleeby (1997). This perspective is fundamental to the values-based perspective of social work in that all people are seen as having dignity and worth as individuals as well as the right to self-determination. Using this approach, the practitioner looks for knowledge, competencies, hidden resources, and resilience in each and every client who comes for treatment. The practitioner moves away from identifying only deficits or diagnosing pathology with DSM-IV toward a broader understanding of person-in-environment client functioning. The strengths perspective has had a significant impact on mental-health ser- vices. Yet the strengths perspective is often seen as only one aspect of a comprehensive assessment, with a diagnostic DSM-IV approach having more importance in a behavioral-health service-delivery system. There have been various attempts to develop standardized measures to assess strengths and competencies (Jordan & Franklin, 2003) and also to incorporate a strengths approach into a more traditional psychosocial assessment. Incorporating a strengths-based assessment process has been used in work with battered women (Lee, 2007). With the current emphasis on evidence- based assessment and practice, much more empirical research is needed on outcomes with strengths-based assessment.

Summary of Current Evidence-Based Assessment for Individuals

There are a number of sources of information that a social worker can use in completing assessments on individual clients. These sources include:

· Background information on clients from case records.

· Verbal reports from clients about their feelings, history, and problems.

· Direct observation of nonverbal behavior.

· Observation of interaction with family members and others in clients’ environment.

· Collateral information from families, relatives, physicians, teachers, employers, and other professionals.

· Tests or other assessment instruments.

Social workers often begin to work with clients after reading lengthy case records. Although there are advantages to having a preliminary understanding of a client before contact is made, the major disadvantage is that case records may unduly influence the social worker’s perception of the client. Case records are often written from a deficit perspective. Frequently, a DSM-IV diagnosis is included that may not be current. This may be especially true in mental-health settings when the client has had a long history of mental-health treatment. Research on whether the assessment process is helped or hindered by the social worker’s prior perusal of a case record is needed.

The primary source of information for assessment should come directly from the client. The practitioner needs to be a skilled interviewer to elicit information that is particularly relevant to the client’s problem. Previously, client assessment was a very lengthy process, often spanning several interviews. The current trend is brief assessment to learn information that is particularly pertinent to the client problem and what will be most helpful in future work. A thorough assessment usually includes the following categories (Cooper & Lesser, 2002):

· Identifying information.

· Referral source.

· Presenting problem.

· History of the problem.

· Previous counseling experiences.

· Family background.

· Developmental history.

· Educational history.

· Employment history.

· History of trauma.

· Medical history.

· Cultural history.

· Spirituality/religion.

· Mental status and current functioning.

· Mental status exam.

· Multiaxial DSM-IV diagnosis.

· Recommendations and goals for treatment.

· Plans to evaluate.

Including an evaluation plan provides an empirical foundation for the assessment process.

A major source of information for assessment comes from the social worker’s observation of nonverbal behavior. What demographic

information do we learn nonverbally—sex, age, race? How is the client dressed? How does the client answer questions? How does the client relate to the worker?

Often, the social worker has an opportunity to observe the individual client in interaction with others—family members, friends, group members, or other professionals. This can be an important source of information about the client’s challenges in personal relationships with others.

The social worker can learn important information about the client from collateral contact with others, including family and other professionals. It is important, however, that the social worker not rely too much on negative reports of family members. Family members may present distorted views of clients based on their own interests. Reports from others should only be a secondary method for receiving information to use in a client assessment.

The final method of gathering information for assessment is through tests or assessment instruments. Because many of these instruments have been standardized, assessment through these measures is considered important in promoting EBP.