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108 ■ II. MeTaTHeorieS for DireCT SoCiaL WorK PraCTiCe

Clients can choose goals for the social worker from a list that has examples, such as ask good questions, model behavior, offer ideas, or give cues. In this way, the client has an opportunity to consider and inform the social worker of the kind of support from the social worker that the client might find helpful or desirable.

SBP does not contend that every possible life goal, or area for development, becomes a ser- vice goal. When individuals find even small success in their attempts to reach goals, barriers in other contexts may become less apparent and goals can be achieved indirectly. For example, a child who has improved self-esteem and self-worth because a worker and teacher have main- tained a strengths focus may be less likely to act out. In addition, strengths may generalize across contexts. If a child’s self-identified goal is to make more supportive friends, and the child actively works on reading subtle cues in relationships in order to improve them, other benefits might also occur such as being able to recognize social cues from a teacher in the classroom.

Progress Monitoring, Evaluation, and Termination

SBP assesses and celebrates progress, early and often. When service goals are created, a time frame for making progress toward each goal should be established. The DESSA-Mini, for exam- ple, has four alternative forms so that a client’s strengths can be assessed once a month. Looking over the entire course of treatment, the DESSA-Mini has a procedure built into the instrument to indicate whether maintenance and/or reliable and meaningful growth in strengths has been achieved. When working with groups of students, tests for reliable and meaningful change can be aggregated across students to determine the typical amount of growth experienced.

It is important to revisit how and when the worker–client relationship will end. The inter- ventions should be clear and measurable so that both the worker and the client are aware of successes and know how those successes relate to the purposeful ending of the relationship. Not all relationships will end abruptly, and some settings allow for a gradual reduction of inter- actions over time. Other settings that do not allow for a gradual reduction of interactions will require clear discussion of termination throughout the phases of work so that the client is pre- pared for the ending of the relationship. Ideally, a client will have some degree of self-determi- nation in forming this plan.

CASE STUDY 6.1

This children’s mental health case example (all names and issues are fictitious) demonstrates how a clini- cian practicing SBP may use the eight SBP tenets outlined in this chapter during the stages of practice described earlier.

Rebecca Marris is a social worker at the Orange Grove Community Wellness Clinic, a com- munity mental health outpatient clinic in central California that serves children and adolescents aged 5 to 18 years and their families. The clinic recently hired a new clinical director who was passionate about implementing SBP in all aspects of the clinic’s work. Yesterday, Rebecca con- ducted a phone intake with Mrs. Vo, grandmother of Nancy Vo, a 14-year-old Vietnamese American high school freshman at the local high school. Mrs. Vo was referred to the clinic by a school counselor.

Engagement

During the 15-minute intake phone call with Nancy’s grandmother, Rebecca had two main goals: (a) to confirm that Nancy was indeed eligible for services at the county-funded clinic and (b) to get Nancy and Mrs. Vo to show up in person at the clinic for a full assessment, if Nancy was deemed eligible. Rebecca began by thanking Nancy’s grandmother for calling and urging her to ask questions if she did not understand something Rebecca said. Mrs. Vo reported that

Bolton, K. W. P. M., Hall, J. C. P. L., & Lehmann, P. P. L. (Eds.). (2021). Theoretical perspectives for direct social work practice : A generalist-eclectic approach. Springer Publishing Company. Created from capella on 2022-05-04 19:52:12.

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Nancy was failing four classes and last week was in a screaming match with another student that had almost led to blows. Upon request, Mrs. Vo also provided relevant contextual informa- tion. Nancy was born in the United States after her mother and grandparents emigrated from Vietnam in the late 1990s. She and her 11-year-old brother, Mark, had been living with Mrs. Vo and her husband (her maternal grandparents) for the past 5 years. Nancy was 9 years old when her grandparents obtained custody of her and her brother, when it was determined that their mother could not take care of them because of mental health issues (she meets criteria for bipo- lar disorder) and prolonged drug use. Nancy’s mother sees the children once a week with supervised visitation. Rebecca told Mrs. Vo that Nancy was eligible for services at the clinic because, as a young person involved in the child welfare system, Nancy’s mental health care at the clinic would be covered by Medi-Cal, California’s Medicaid program. Rebecca then invited Nancy and her grandmother to come to the clinic the next day for an assessment. Knowing that many families never make it past the intake stage, Rebecca tried to sound welcoming and friendly. She tried to inspire hope that clinic services could actually help Nancy by mentioning that the clinic has served many 14-year-old clients who are dealing with school issues. She asked how Nancy and her grandmother would be getting to the clinic and mentioned that the clinic provides free bus tickets for clients who need them.

Assessment

Nancy and her grandmother arrived at the assessment appointment the next day. Rebecca offered them drinks and snacks, asked if they needed any reimbursement for their travel costs to the clinic, and then began the assessment process. Recently, in an attempt to become more strengths based and family centered, the clinic had adopted a new assessment form called the Child and Adolescent Needs and Strengths (CANS) assessment (Lyons, 2009). This assessment requires the clinician to document both problems and strengths instead of just recording prob- lems and symptoms. During the 2-hour assessment, Rebecca first spoke with the grandmother and Nancy together.

Mrs. Vo reported that the family has a small income from a bakery they run out of their home, but business had slowed recently and they are behind on their mortgage payments. Though they have limited English skills, they are eager to be involved in all aspects of Nancy’s and Mark’s lives. Nancy, though somewhat socially isolated at school, has up until now gotten nearly straight As. Her school is ranked no. 1 in the district and her grandparents want her to enroll in the free precollege tutoring program offered after school. However, Nancy is currently failing several classes and has not been sleeping at night, which her grandmother noticed because Nancy has been falling asleep at the table while doing her homework. Her grand- mother added that Nancy has mood swings now, more than ever before, and it is harder to be around her.

At the beginning of the conversation, Nancy’s grandmother did most of the talking and Nancy sat with her hands crossed, looking at the floor. Rebecca asked Nancy directly what she liked to do for fun—partly as an engagement strategy and partly to begin to inquire about potential strengths. Nancy took a moment to respond, and her grandmother jumped in, saying that Nancy used to read comic books but had recently stopped. Rebecca listened politely to the grandmother, acknowledged her comment, and then redirected the conversation back to Nancy to learn more about the comic books from Nancy’s perspective. It was a careful balance because Rebecca wanted to make sure that both the grandmother and Nancy felt like they were collabo- rators and partners in the assessment process.

At one point, Nancy’s grandmother started to go into detail about the time Nancy’s mom overdosed and had to be hospitalized, the incident that led to Nancy and Mark being placed with their grandparents permanently. Rebecca was not sure she needed to hear all the details in order to work effectively with Nancy in the present, and she did not want to retraumatize Nancy in any way, so she made a brief reflective statement and Mrs. Vo felt heard, but then

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gently changed the topic. At this point, Rebecca wanted to make sure that Nancy felt that her unique voice was valued in the assessment process. So, Rebecca asked to speak with Nancy one-on-one for a few minutes. After the grandmother left the room, Nancy seemed to relax.

During their time one-on-one, Rebecca purposely asked questions to assess both problems and strengths at both the individual and the environmental level. Rebecca started off with strengths because strengths tended to be easier to talk about for many clients and she was still building rapport with Nancy. To inquire about an individual-level strength, Rebecca asked Nancy to tell her about something she enjoyed doing. Nancy reported that she had a job as a babysitter for her next door neighbor’s children and that she really liked the two kids. Rebecca used this opportunity to point out a strength, noting that it sounded like Nancy really cared about the kids and that she was a big help to her neighbor. To learn about her environment, Rebecca asked Nancy to tell her a bit about her neighborhood. Nancy responded that she liked living in her grandparents’ neighborhood better than living in her mom’s neighborhood because she felt safer when she was walking home from school and the streets were prettier. Rebecca noted on her assessment that the neighborhood sounded like an environmental strength for Nancy.

Rebecca then moved to sensitively asking about some potential areas in her life that Nancy wanted to be better right now and some goals she wanted to achieve in the future. Nancy immediately answered that she wanted her experience at school to be better. Rebecca said that it sounded like Nancy had been having trouble at school, and asked what it was like for her at school. Nancy responded that she hated everyone because they were so nosy. Rebecca asked Nancy to give her an example of this, and Nancy reported that everyone at school knew that her mom got arrested last week for shoplifting and that the police were keeping her in jail because she had traces of drugs in her blood test. Nancy heard several students talking about it in a class.

Rebecca had not known that Nancy’s mom was back in jail, and responded with empathy and that she was sorry to hear that. Nancy said angrily that her mom had promised Nancy she would not use drugs again and now Nancy would not be able to see her for a long time. Rebecca acknowledged how upsetting it must be to have heard this. She then asked Nancy what she had been doing to cope. Nancy reported that she listened to music at night really loud on her head- phones and that helped. Rebecca pointed out a strength, saying that it was great that Nancy had found something that helped. Nancy smiled a bit at this comment. Rebecca also pointed out that Nancy knew herself better than anyone else, and that Nancy would be in the best position to decide what might work for her at home and in their interactions together.

As Mrs. Vo had earlier mentioned that Nancy was not sleeping at night, an individual-level barrier, Rebecca asked Nancy to tell her about what the nighttime was like and how sleeping was for her. She purposely asked the question in a vague way so that she did not assume that sleeping was a problem for Nancy. Nancy reported that she could not fall asleep and “I just can’t stop thinking.” Curious to learn more about this, Rebecca asked Nancy to tell her more about what that was like. Nancy reported, “I used to be able to just get my brain to stop, but now it has so many thoughts I just can’t sleep.” Rebecca asked Nancy to tell her about these thoughts, and Nancy reported that they were mostly worrying about her mom. Rebecca reflected Nancy’s statement and Nancy got somewhat teary eyed. Rebecca continued to use empathic reflections to ensure Nancy felt understood. Rebecca then transitioned the conversa- tion by asking Nancy to tell her what it might be like for her if she were to be able to sleep better at night. Nancy’s demeanor shifted from sorrowful to more hopeful when Nancy stated that when she doesn’t sleep, she “just feels run down all the time” and that it would be “awesome” if she could get the thoughts to “turn off” at night. Nancy also said that she would have “way more energy” the next day if she could get some sleep. In order to pivot into a potential strengths-based goal rather than staying focused on a problem, Rebecca then asked Nancy to talk more about what other things getting more sleep might help Nancy to accomplish. Nancy stated that it might help her to do better at school and that it might help her not be so “cranky”

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with her grandma. Rebecca then reframed Nancy’s statement in a positive light by saying, “[So] even though you and your grandma don’t always get along you care about your grandma and want things to go well between the two of you.” Nancy agreed with that statement, and Rebecca affirmed Nancy for her good intention. Rebecca then linked two other identified bar- riers to Nancy’s strengths-based desire to have a better experience at school. Rebecca stated, “You also want to have a good experience at school and you think two of the things getting in your way are feeling like people are talking about your family negatively and not getting enough sleep.”

At the end of the assessment, Rebecca thanked Nancy and her grandmother for coming in. In order to indicate her hope and optimism that clinic services could help Nancy, Rebecca told Nancy that the clinic works with many young people with similar goals and barriers and that many young people found therapy useful in helping them move toward leading a life they wanted to lead. She asked if Nancy would be interested in coming back for some therapy appointments. Nancy agreed, and so they scheduled an appointment for the following week.

After they left, Rebecca entered the assessment information into an online database and wrote up her assessment case formulation, making sure to include both problems and strengths. While Rebecca assessed that Nancy did not currently meet criteria for any mental disorders as described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2013), she indicated in her notes that, particularly as Nancy had described some symptoms consistent with various mental disorders and given her mother’s mental health history, the therapist should monitor Nancy for other symptoms that might result in her meeting criteria for other disorders in the future. Rebecca was careful to document both environmental and individual strengths. The neighborhood; the bakery; potential positive rela- tionships with grandma, her brother Mark, her neighbor, and neighbor’s children; access to free afternoon tutoring; and attendance at a highly ranked school were all identified as potential environmental strengths that could be used in planning later. Rebecca’s past history with obtaining As, her love for reading, her good intentions, her responsible babysitting skills, her desire to have a good school experience, and her desire to get along with her grandma were all identified as potential individual strengths that could also be used in planning.

Planning and Intervening

Rebecca’s intention was to have the planning be a collaborative effort between her and Nancy. When Nancy came back for her first therapy session, Rebecca asked Nancy if they could spend some of their time together over the next few weeks thinking about their service goals. Nancy agreed, and so Rebecca asked Nancy to tell her what she hoped to get out of the sessions and what her goals were. Nancy said that she wanted to “stop failing my classes,” “stop my brain from going crazy at night,” and “stop feeling so angry at everyone.” They discussed this, and Rebecca purposely guided the goal setting to state the objectives in positive language that focused on constructing skills and achieving goals instead of only reducing symptoms. They tried to be very concrete in their goals, coming up with: “Make a plan for when I can’t sleep at night because this will help me do my homework,” and “Make a plan for when I feel angry at my teachers or classmates because this will help me pay attention in my classes and help me to enjoy school.” Rebecca then asked Nancy what would help her to meet these goals. Nancy did not have any ideas, so Rebecca pointed out that Nancy had already named a coping skill—lis- tening to music when she was having trouble falling asleep—and asked her what else would help her to feel calm and relaxed at night. She also asked about resources that currently exist in Nancy’s life that she could call upon, encouraging Nancy to think about a teacher or a friend who might be able to meet with her during the lunch period to help her catch up in her classes. Together, they decided that they would check in at the end of each session to see how they both felt it had gone. They also agreed to do a slightly longer check-in every four sessions to evaluate progress toward Nancy’s goals.

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After their planning session, Rebecca continued to consider several different interventions to identify which would be the most effective for helping Nancy to meet her goals. She decided to use two interventions that employed many strengths-based principles and fit well with a strengths-based approach to social work practice: motivational interviewing and solution- focused therapy. Motivational interviewing was useful because it provided a framework for exploring ambivalence around change, which was the case for Nancy with regard to her aca- demics. Solution-focused therapy was useful because it provided a concrete way to focus on exploring past coping skills and developing new coping skills. Both of these interventions focused on hopes and dreams and centered the client voice, two characteristics that are consis- tent with SBP. Rebecca discussed these interventions with Nancy at their next appointment, and Nancy said that they sounded good to her. Rebecca asked Nancy to please make sure to ask her any questions and to let her know if she had any feedback for her.

Monitoring Progress, Evaluation, and Termination

Rebecca always left 5 minutes at the end of each session to briefly check in to see how Nancy felt about the services. After four sessions, Nancy and Rebecca spent half of a session discussing Nancy’s goals and assessing how much progress they had made toward those goals. Nancy reported that she felt like she was sleeping a bit better at night but that school was still not going well. She still felt isolated by her peers, and catching up in her classes was a true challenge. Rebecca made sure to praise Nancy for making such great progress toward one of her goals. Then Rebecca suggested that they update Nancy’s goals to focus on maintaining her sleep and setting more detailed school goals. After discussion, Nancy identified two new, specific, more targeted goals for school: (a) meet with an after-school tutor two times a week for 3 weeks to prepare for an upcoming history test and (b) attend a meeting of a school club she was inter- ested in so that she could make friends with positive people who held similar interests. Rebecca helped Nancy to phrase these objectives in language that focused on constructing new skills and obtaining larger meaningful goals instead of just reducing symptoms.

After eight sessions, they reassessed progress and rewrote goals again. During the reassess- ment of Nancy’s academic goals, Rebecca continued to elicit from Nancy individual and envi- ronmental strengths. Rebecca accomplished this by asking Nancy again about strategies and strengths she had used in the past when Nancy had been successfully achieving good grades. Nancy was able to identify strengths she had not described before, such as ways she had struc- tured her time (individual strengths) and also the added homework assistance Nancy received from her grandmother when needed (environmental strength). Her grandmother had not been able to help Rebecca as much recently because she was spending time in the struggling bakery. Rebecca probed to see if other people had helped Nancy along the way, and Nancy said that last year her neighbor, who sometimes let Nancy babysit, would also occasionally help Nancy with her homework. The neighbor had usually helped Nancy when Nancy’s grandmother did not understand Nancy’s homework due to language barriers. In addition to mining for strengths from Nancy’s past, Rebecca also asked questions that helped Nancy describe how achieving good grades and having a better school experience might influence her life in the future. Nancy described that doing well in her classes might ultimately help her obtain her goal of going to college and perhaps becoming a nurse. Rebecca periodically helped Nancy revisit her future dreams in relation to school performance in order to keep the discussion anchored on positive life goals rather than the current academic struggles. Rebecca and Nancy were then able to be flexible and adjust the plan to include some of the strengths identified through Nancy’s past successes. Rebecca kept revisiting Nancy’s academic hopes and dreams for the future in order to keep Nancy engaged in moving forward even when it was difficult or when setbacks occurred along the way. Rebecca also asked Nancy if she wanted to continue for another four sessions as she was still working toward meeting her school goals. Nancy agreed that this would be helpful.

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