Readings

Families in Society: The Journal of Contemporary Social Services | www.familiesinsociety.org | DOI: 10.1606/1044-3894.3822

©2008 Alliance for Children and Families596

ABSTRACT

Assessment and formulation, the gathering of information about a client, and the conceptual- ization of the client or situation are the essential elements that mark a thoughtful approach to client care. This process has been shaped over time by changes in orientations to knowledge, new theories, new practices, and political and institutional pressures. Currently, there is an intense debate concerning the nature of social work practice, especially the assessment and formulation process. In this context, we review traditional approaches to formulation in light of contempo- rary understandings and trends. We present a model for formulation that highlights multiple ways of knowing and includes ecological, cross-cultural, psychodynamic, systemic, biological, and spiritual components. Social justice is the value that is foundational to the process.

PRACTICE APPRoACHES

This is a time when researchers, educators, and prac- titioners are debating the essence of social work (Gambrill, 2006; Graybeal, 2007; Sellick, delaney,

& Brownlee, 2002; Witkin & Harrison, 2001). The clinical practices of assessment and formulation are at the center of this debate. The form that clinical social work practice takes in the future will be strongly influenced by the way that social work educators and practitioners conceptualize the processes of assessment and formulation. As teachers of practice, and as practitioners ourselves, we wish to enter the debate and offer a model of assessment and formulation for the consideration of educators, students, and practitioners.

The model is comprehensive and multidimensional. It highlights several knowledge areas considered important in the process of understanding a client or situation. The domains that we have selected are not new; they have long been the ways that social workers think about clients. We

consider it especially important in a time of change to review traditional practices and reconfigure them in light of contemporary theories and approaches. The model will help clinicians hold on to full, rich, and complex under- standings of clients and clinical work.

In this material we first define what we mean by the terms assessment and formulation. Then we discuss the nature of current challenges and show how they emerge from historical trends in social work. Having explored current and past themes, we present our model and dem- onstrate its application with a case example.

Defining Terms—The Language of Social Work

Work with a client begins with eliciting information con- sidered relevant to the issue with which the client presents

Assessment and Formulation: A Contemporary Social Work Perspective

Ruth G. Dean & Nancy Levitan Poorvu

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(mattaini & Kirk, 1991). We refer to this process as the assessment. We define formulation as a focused, brief conceptualization of the client or situation, based on the assessment. It highlights the central issues, offers a ten- tative understanding of them, and sets the groundwork of the plan for intervention that follows (madsen, 2007; Perry, Cooper, & michels, 1987; Ross, 2000). Assess- ment is an ongoing process that leads to inferences and hypotheses that contribute to the developing relationship between worker and client as they reflect on themes and increase their understanding of an issue or problem (Ger- maine & Gitterman, 1996). In most models of contem- porary practice, the way social workers formulate their cases is developed in collaboration with clients, privileg- ing their views and supporting their strengths (madsen; Parton & o’Byrne, 2000).

models for assessment developed in the fields of psy- chiatry, psychology, and family therapy have made impor- tant contributions to the ways social workers formulate their cases. Social workers must be able to speak the languages of the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV–TR; American Psychiatric Association, 2000) and psychodynamic, developmental, behavioral, and family systems theories, to name a few current influences. But borrowed understandings leave out interests essential to social work. our model integrates multiple perspectives, some of which originated in other disciplines, within an orientation that is consistent with the values, theories, practices, and language of social work. This approach, highlighting multiple ways of knowing, falls within a constructionist perspective. Forces in social work representing different views would challenge this choice. We now consider some of these current challenges.

Current Challenges

Powerful intellectual and political and social forces are challenging the social work practices of assessment and formulation. In the academy, two very different orienta- tions to knowledge have been the source of strong debates that began in the 1960s with critiques of the ideal of objec- tive truth and an objective scientific methodology (Irving, 1999; Sellick et al., 2002). These orientations are variously referred to as modern and postmodern, empiricist and postempiricist, and realist and constructionist (Iversen, Gergen, & Fairbanks, 2005). They have powerful impli- cations for social work education and practice; they also direct the ways in which assessment and formulation are conceptualized and enacted.

Those steeped in empiricist models, such as the advo- cates of evidence-based practice, argue for a research- based, scientific orientation to assessment and treatment planning (Gambrill, 2006; o’Hare, 2005; Rosen, 2003).

Scales and assessment instruments may be used to help name the problem being treated and to offer a baseline for assessing change (o’Hare). In this model, although clients’ views are considered, the worker’s expertise and responsibility for assessment and treatment planning is stressed (o’Hare).

The postmodern or constructionist orientation empha- sizes the shifting, evolving, contextual, and fluid aspects of knowledge, and this orientation questions whether objectivity is at all possible in selecting the information that goes into a formulation (dean, 1993; Iversen et al., 2005; Parton, & o’Byrne, 2005). multiple perspectives are utilized, based on the belief that all views are partial and that no single theory or perspective has a monopoly on the “truth” of a situation. Clients’ understandings and mean- ings are privileged, and the process of formulation involves collaboration between workers and clients (madsen, 2007).

In addition to pressures emanating from these ideo- logical differences, political and institutional changes in the United States have altered the context in which social work practice occurs with implications for the assessment process. The conservative political turn that has gripped the United States in the past 30 years has led to disman- tling the safety net established by President Franklin Roosevelt during the New deal (Krugman, 2007). This has meant decreased support for social services, tighter agency budgets, and pressure to limit workers’ hours to those spent in direct client contact (Barlas, 2006; Schneider, Hyer, & Luptak, 2000; Stoil, 2001). The man- agement of care by third-party payers requires medical (psychiatric) diagnoses. Formulations are often limited to DSM–IV–TR diagnostic categories, determinations of risk, problem lists, and the specification of measurable outcomes (Cohen, 2003; Furman & Langer, 2006; mishne, 2004; Schneider et al., 2000).

In this stressful practice climate, strongly held differ- ences have emerged among social workers concerning the priorities of the evaluation process. Some emphasize measurable behavioral change; some focus on “strengths”; others focus on culture, context, ecological factors, politi- cal inequalities, social injustices, intrapsychic phenomena, and systemic issues. Tensions inherent in these differences have at times resulted in oversimplified assessments that represent the views of a single camp. Although most social workers agree that some form of inquiry and assessment is needed, what this should consist of is unclear.

We do not wish to take sides in this debate, for each side has something to contribute to a discussion of assessment and formulation. Like the empiricists, we see the need for establishing a baseline formulation of the problem that will guide the interventions that follow and make it possible to evaluate outcomes. But, in agreement with the constructionists, we believe that any view is tentative

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and will (and should) dissolve or shift as the work pro- ceeds. Although we see the necessity for using words and categories to organize thinking, we also believe, with the constructionists, that words construct rather than reflect the ways we see the world. The words we use to construct a client can be morally evaluative and negatively affect the ways that others see him or her (Urek, 2005). These words have serious, damaging effects and forever obscure the person he or she is. Therefore, we must choose the words we use in a formulation very carefully, and hold them lightly, always ready to be changed. We prefer descriptive to diagnostic terms and, if possible, the use of clients’ words to describe their plights. We support a collaborative effort in which clients’ views are primary (construction- ist). But we also see the need for the worker’s expertise to guide the process (empiricist). Thus, we see the work of assessment proceeding within the tensions of differ- ing intellectual traditions. These tensions have existed throughout the history of the profession.

The History of Assessment and Formulation in Social Work

From early in its history, social work has struggled to lose its association with friendly visiting and be recognized as a profession. In 1917, mary Richmond’s seminal book, Social Diagnosis, set in motion assessments that involved investigative studies of clients and their families and, based on these studies, the development of diagnoses that defined treatment. Although strongly influenced by the medical model, Richmond incorporated ideas of commu- nity context and individual and family strengths into her view of diagnosis.

Since these early beginnings, changes in the assessment and formulation process can be divided into three catego- ries: shifts related to ideological differences, the influence of new practice models and approaches, and recurrent themes. In the material that follows we highlight each area.

Conceptual Shifts Whereas early evaluations employed a linear, cause-and- effect view of problems, an appreciation for multicausality gradually emerged (Hollis & Woods, 1981). The need to collect a large number of facts about a client or situation was tempered by recognition of the importance of the meaning that events and situations had for clients. A focus on relationships and the client’s relational history was prominent early on (Graybeal, 2007; Perlman, 1979); in the past 20 years, there has been more interest in problems, solutions, and behavior (de Shazar, 1985; madsen, 2007).

Interest in developing a scientific base for the profession moved social work beyond the earliest forms of assess- ment, which were based on determinations of worthiness

(Brill & Taler, 1990; Canda & Furman, 1999; Richmond, 1917). However, there have been strong differences as to the ways that science is defined, along with notions of how sci- entific interests should affect the process of assessment and treatment (Graybeal, 2007; Witkin & Harrison, 2001).

Assessments became more sensitive to the impact of race, culture and ethnicity, gender, and sexual orientation (Boyd-Franklin, 1989; Laird & Green, 1996; mcGoldrick, 1998; Panos & Panos, 2000; Pinderhughes, 1989). The impact of immigration, whether recent or in an earlier generation, has become a more current focus, along with greater understanding of the strain of acculturation and of intergenerational conflicts in immigrant families (mir- kin, 1998; mock, 1998).

Understanding of the role of social injustices and oppression as causal factors in people’s troubles and the need to assess their impact has always been part of social work thinking. Issues of reform and community solidar- ity raised by Reynolds (1973) in the 1930s evolved into later models of empowerment that focused assessments on the strengths of individuals and the resources in their communities (Lee, 2001; Reynolds; Weinberg, 2006).

Influence of New Theories, Models, and Approaches As new theories, models, and approaches emerged in the human sciences, they were taken up by social work and were influential in assessment and formulation. Psycho- analytic theory, as it took hold in the United States in the 1940s, turned social workers’ attention to intrapsychic causes and personal history (Hollis & Woods, 1981). This psychoanalytic focus was followed in the 1970s by a wave of family therapies that focused on larger systems, groups, and family interactions and structures (Brill & Taler, 1990; minuchin, 1974; Shulman, 1992). The psycho- dynamic and systemic methods spawned many schools and therapies, which were readily absorbed and then discarded by social work programs (H. Goldstein, 2001). Each new model prioritized something slightly different in the evaluation and treatment process.

Social work’s basic interest in context, expressed early in the “person-in-environment” configuration, was broad- ened with the introduction of the ecological model (Ger- maine & Gitterman, 1996). Increasingly, there has been a turn toward a risk and resilience form of ecological model that allows workers to conceptualize a problem at multiple levels and consider the internal or external risk and pro- tective factors (Corcoran & Nichols-Casebolt, 2004).

Recurrent and Expanded Interests In a reaction to the deterministic and diagnostic direc- tions of Freudian theory, humanistic concerns with indi- vidual will and people’s strengths emerged at different

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historic times, as seen in the Functional School in the 1930s (Robinson, 1930), and the “strengths perspective” in the 1990s (Saleeby, 2005). Belief in the importance of focusing on health instead of pathology changed the direction of assessments (Saleeby, 2005; Weick, 1986). The biological part of a “biopsychosocial” formulation was broadened to include considerations of health, fit- ness, genetic endowments, predispositions, and “normal” changes associated with life phases, such as aging. The concept of able-bodiedness reshaped consideration of physical challenges. New understandings of mind–body connections led to an awareness of the relationships between spirituality and religious beliefs to well-being and the importance of including these areas in assess- ments (Griffith & Griffith, 2003; Perry, 1998).

Finally, the debate about the relationship of science to social work practice has been recurring and, at times, sharp and divisive. It is currently represented by the evidence-based practice movement (o’Hare, 2005). The practices of assessment and treatment that this movement supports collapse models of research and practice, so that the process of formulation becomes problem analysis (o’Hare). Problems are rendered in the form of research questions and then used to search the professional lit- erature for interventions supported or informed by con- trolled experiments. Evidence-based practices currently available are studied in terms of their applicability and appropriateness in a particular situation and modified as necessary to the situation at hand. outcomes are defined operationally and then assessed according to standard- ized outcome measures (Rosen, 2003).

Ongoing Tensions Tensions observed in these conflicting approaches have carried forward in current practice. These include con- flicts inherent in balancing the profession’s commitment to strength-based assessment with models or settings that require diagnosis of illness, deficits, or risks. There are additional conflicts between a commitment to a collabor- ative approach with clients and situations that require the social worker to render an “expert” or diagnostic opinion (e.g., assessment of suicidality). Finally, there are strong differences regarding ways to ensure the effectiveness of social work practice. These ongoing strains are not neces- sarily resolvable since responses to them emanate from very different knowledge orientations. We believe they add to the vitality of the profession.

Components in Social Work Assessments and Formulations

Social work practice has been shaped by interests and necessities that fluctuate over time. But the values of the

profession are foundational. They have remained con- stant, but their meaning has evolved as social work prac- titioners have become more cognizant of the dimensions of power, oppression, and difference.

Social Justice Perspective A primary social work value is the belief that all human beings should be treated as unique individuals with cer- tain basic rights including the right to self-determination. The profession’s commitment to social justice emphasizes that many peoples’ problems reflect the difficulties of living in an unjust and oppressive society. These values are reflected in social work formulations that include the uniquely individual characteristics that affect a person’s well-being and the institutional and political dimensions of people’s problems.

Thus, formulation begins with a social justice perspec- tive that takes into account the ways in which social forces and conditions constrain clients’ lives and affect the ways we see them. These forces include the devastating effects of poverty and violence along with prejudices enacted in relation to gender, race, age, class, ability, sexual orienta- tion, and other differences. A social justice perspective that is sensitive to power and social inequities also focuses social workers on their social identities and power in rela- tion to clients. This sensitivity to differences can make it less likely that oppression will be unwittingly repeated in the worker–client relationship.

Ecological Perspective An ecological perspective emphasizes the dynamic trans- actions between people and the multiple social systems, subsystems, and environments in which they participate. This understanding requires careful observation of the actual places where clients spend their time (homes, schools, communities, and streets) to determine if clients’ interactions with their environments are enriching and supportive, or limiting and destructive. It includes using structural data that provide a demographic understand- ing of the resources and challenges of clients’ neighbor- hoods, with attention to community-based indicators of well-being (Ung, 2004). An ecological assessment begins with clients’ assessments of their communities and includes their creative solutions to community challenges. An empowerment approach engages diverse resources to enable clients to find solutions, expand their capacities, and enhance the possibilities of their communities.

Diversity and Cross-Cultural Sensitivity Since the 1970s, social work literature has been particu- larly attentive to the impact of culture, race, and ethnicity on peoples’ identities (Atkinson, morten, & Sue, 1979; Boyd-Franklin, 1989; mcGoldrick, Giordano, & Pearce,

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1996; Pinderhughes, 1989; Staples, 1978; Sue, 1981). Early clinical approaches to diversity, coming from a modernist orientation, used more static and essential views of eth- nicity, culture, and race.

In contemporary practice when a postmodern frame is used, the changing, evolving, contextual, and interac- tive nature of identities is stressed (Laird, 1998). Social workers are encouraged to appreciate the limits of their knowledge and work from a “not-knowing” and curious position, one that supports empathic attunement and learning what it is like to be in another’s shoes (Anderson & Goolishian, 1992; dean, 2001). Clinicians need to be aware of the prejudices, attitudes, and distortions they carry in regard to other groups and to be self-critical and open to new understandings (Comas-diaz & Jacobsen, 1991; Hamilton-mason, 2004; Perez Foster, 1999). Sensi- tivity, respectful curiosity, openness, and self-awareness are the hallmarks of a formulation undertaken from a cross-cultural perspective.

Systemic Approaches A systemic perspective focuses specifically on the systems in a client’s life such as the family, workplace, church, or community. The art of formulation lies in making a deter- mination of the size of the client system to be approached and the necessary scope of the inquiry. The work might be with a family subsystem, the nuclear family, or members of the extended family; it might include several families in the same community who have a mutual interest, or several community groups (e.g. teenagers, their parents, and the police). The focal system could change as issues improve in one area and become apparent in another.

There are a multitude of systemic theories and approaches to understanding small groups and fami- lies. The direction of the formulation and clinical work depends on which theories are used. The field has moved from a focus on assessing structures (minuchin, 1974) to understanding interactive processes (Lowe, 2004). more recently in narrative approaches, attention is being given to clients’ stories. If a client’s story is problem-saturated, there is an effort to help the client replace it with stories of strengths and resilience, often located at the margins of a client’s awareness (Anderson & Goolishian, 1992; White & Epston, 1990). Clients and social workers become part- ners in co-constructing new narratives.

A systemic perspective focuses on external, observable patterns and processes, as well as articulated stories. To understand the client’s problem from a psychological per- spective, the focus turns to intrapsychic phenomena.

Psychological Perspective A psychodynamic approach posits that life events, situa- tions, and early relationships are internalized and influ- ence ongoing behavior (E. Goldstein, 1995; Hollis &

Woods, 1981). There have been many psychodynamic “schools”; each highlights different aspects of behavior and development and shapes the lens of the formulation process accordingly. Some focus on conflict and resolu- tion; others, on early relational experiences that shape ongoing behavior; and still others, on self-development or attachment. All assume that development occurs in stages—each phase with its own challenges and oppor- tunities—and that the way that these challenges are managed affects a person’s ongoing development and behavior (Erikson, 1950; Perry et al., 1987). Individual responses are seen as adaptive and as representing the best possibility for the person at the time they occur, even if they become maladaptive later in life. The relationship between the social worker and client is considered an additional source of insight regarding the client’s rela- tional style and patterns.

In this discussion of factors to be considered in formu- lation we have moved from a broad view of political and institutional forces to a consideration of neighborhood environments, family systems, and individual psychology. At the individual level, two additional aspects of human functioning to consider are biology and spirituality.

Biological Perspective The biological component of a biopsychosocial formula- tion has gained importance, with genetic factors receiv- ing particular attention at present. Patterns of substance abuse and family history of mental illness are included in a biological assessment, along with indicators of well-being or illness (Bisman, 2001). Cultural beliefs about health, disease, and healing need to be understood; it is important that West- ern biases not be imposed on clients from diverse cultures (Panos & Panos, 2000). Past and present sexual behavior and attitudes, as well as sexual dysfunction, would be appropriate subjects for a formulation if relevant to the issues for which the client is seeking help.

Assessments of persons with disabilities need to dis- tinguish between impairment, the “physical, sensory, cognitive, or systemic condition that directly imposes a reduction in certain functions,” and disability, “those bar- riers and reductions in function imposed by the physical and psychosocial environment” (olkin, 1999, p. 89). The locus of impairment is in the person whereas the locus of disability is in the sociopolitical environment (olkin).

Spiritual Perspective Clinicians have not always explored the spiritual compo- nent in clients’ lives (Gotterer, 2001; Thayne, 1998). Yet the lack of assessment of this dimension can prevent cli- ents and clinicians from using the full array of resources that have been shown to be helpful (Canda & Furman, 1999; Gotterer; Perry, 1998). Information about a person’s spiritual perspective and religious beliefs offers insight

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into the ways they see themselves and the world (Thayne). definitions of spirituality differ and may or may not be connected to a person’s membership in a formal religious group (Canda & Furman; Gotterer). Recent writers have offered ideas about sensitive ways to conduct a spiritual and religious assessment (Griffith & Griffith, 2003; Par- gament, 2007). Although spiritual and religious beliefs can serve as sources of strength, they can also be prob- lematic for clients.

We have identified seven potential components of a social work assessment: social justice, ecological, cross- cultural, systemic, psychodynamic, biological, and spiri- tual. Now we will present a model that shows how these areas are woven together into a formulation.

Model for Formulation: Process and Format

Work with clients inevitably begins with an inquiry guided by the reasons for referral. during the assessment phase, information is collected and recorded in a number of domains including environmental factors, relevant sys- tems (i.e., family, school, work, etc.), cultural background, and developmental history. The social worker observes the client’s appearance, affect, behavior, and ways of relat- ing and telling his or her story. The client’s strengths are highlighted. Information collected during the assessment phase that is considered most important to understanding the client or situation is then briefly summarized in the formulation. The formulation, as written or presented, begins by repeating the client’s identifying demographic informa- tion and includes relevant identifying information about the worker. Each of the parties brings aspects of identity to the interaction that will affect the relationship, the possibilities for understanding, and the work they do together. Including information about the worker makes it possible to note and highlight differences, similarities, and the interactive possibilities and challenges.

Information collected during the assessment phase that is considered most important to understanding the client or situation is then briefly incorporated in a discussion of the issues from any of the perspectives that pertain: social justice, ecological, cultural, systemic, psychodynamic, biological, and spiritual. The co-constructed formulation continues with a statement of goals and a plan of interven- tions consistent with these goals. There can be a consid- eration of aspects of the clinical relationship that might be helpful or problematic. If research is available to guide the treatment planning, it is cited in the formulation as part of the justification of the intervention to be used. The formulation concludes with a specification of desired out- comes and a plan for evaluating results. When possible, goals are stated in measurable terms, but we would not restrict goals to those that can be quantified.

The scope of the inquiry and the depth of the formula- tion are dependent on the client’s concerns, the function of the agency in which the client is seen, and the time available for the work. Although the worker is guiding the inquiry, a collaborative approach should be maintained. There needs to be a balance between the worker’s use of questions and space for clients to tell their stories in ways that are natural and holistic. At the end of the process, the worker and client together make decisions about priorities. The following example of a client with whom one of us worked (Poorvu) is provided to demonstrate the process of assessment and formulation as illustrated in Figure 1.

Example

Presenting Problem Angela, a 20-year-old White Irish woman, is referred for support by her son’s pediatrician, when 10-month-old Brian is diagnosed with malabsorption and severe chronic bowel disease and admitted to the hospital. She reports that Brian has always been difficult to feed despite her efforts at trying different types of bottles and formulas. Brian has numerous stools each day, increasing the money spent on disposable diapers because Angela does not have time to wash cotton ones. Angela admits that her frustra- tion often renders her tearful and hopeless about being an adequate mother for Brian. She states, “I just thought Brian was small and troublesome. I didn’t think he was really sick.” The hospitalization has added to her stress, despair, and difficulty sleeping.

Summary of Biopsychosocial Information Angela, a single mother, was abandoned by the baby’s father, her high school boyfriend, after telling him she was pregnant. She is determined to manage Brian’s care alone. Angela lives with her son and mother in a rented

I. Identifying demographic information regarding client and worker: reason for referral, agency context, presenting problem, and history of the problem.

II. Summary of relevant biopsychosocial information: This may include client’s history, environmental situation, cultural background, class, family, work and other systems, individual psychological factors including developmental history, biological factors, and spirituality.

III. Formulation: Brief conceptualization of the issues from social justice, ecological, cultural, systemic, psychodynamic, biological, and spiritual perspectives as relevant.

IV. Exploration of literature for evidence-informed interventions. V. Goals, interventions to be used, and justification for

these choices. VI. Advantages and challenges in the clinical relationship. VII. Plan for evaluation.

Figure 1. Assessment and formulation outline.

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apartment (a two-bedroom, third-floor walk-up) in a working-class, tightly knit, mostly Irish neighborhood in Boston. In addition to her responsibilities as a mother, Angela is also caring for her mother, who is frail, has chronic emphysema, and requires oxygen and an array of other services. This means that Angela cannot stay over- night with Brian at the hospital. Her father, an alcoholic, is homeless, unemployed, and in minimal contact with the family. Angela’s girlfriends help out, but she knows that her mother really wants only her. Thus, she feels torn between the needs of her mother and her son.

Angela had heard stories from her immigrant grandpar- ents about prejudice against the Irish that they encountered upon arriving in Boston. She expects similar treatment, saying that Irish Catholics should “stick to their own kind.” Her mother insists that one doesn’t share one’s busi- ness outside of the family. Angela has become increasingly uncomfortable with the growing Hispanic population in her neighborhood and with the gang of boys who hang out at the corner convenience store.

Angela is unemployed. She and Brian have the support of several government assistance programs, including Temporary Assistance for Needy Families; the Special Supplemental Nutrition Program for Women, Infants, and Children; and medicaid. She wonders if her poverty will prevent Brian from getting the treatment he needs at the hospital clinic. His condition requires that he be fed with breast milk that has to be bought at a high cost. Angela states, “That must be for rich people; how will I ever afford it?”

Angela has many close relationships with women friends and a positive relationship with her mother. demonstrat- ing her capacity for insight, Angela says that her early negative experiences with her father made her untrusting of men in general. She fears that dr. Smith might judge her for being a “welfare mom” and refuse to be Brian’s pediatrician.

Angela has never seen a social worker and states, “Strong people shouldn’t need help.” Angela wonders how it will be to talk to a non-Catholic social worker. Comforted by her worker’s being the same age as her mother, Angela decides to give the relationship a try. The clinician is aware of her maternal and protective feelings toward Angela, as she remembers what it was like to be a new mother.

Formulation This 20-year-old new mother and her family contend daily with the effects of poverty, poor health, and inequities in the health care system. Her social worker, a 50-year-old married Jewish mother of three adult children, lives in comfortable circumstances and takes for granted access to good health care. It is important that the worker be mindful of these dif- ferences in circumstances.

Angela lives fearfully, concerned about the shifting demo-

graphics of her neighborhood and the increase in gun vio- lence and gang-related crime. She has been raised with core beliefs about sticking to one’s own kind, and she expects to be misunderstood by others. She has few models of women empowered to make beneficial changes, since she has been surrounded by women who share her circumstances and sense of a lack of power. She is easily intimidated by hospital staff and fears criticism from the doctor. Angela appears to have a secure relationship with her mother. But she is stressed by being in charge of a multigenerational family with seri- ous needs, at an age when she might benefit from nurturing. While she is able to advocate well for herself, and to negotiate difficult welfare systems, the frustrations at times overwhelm her and exhaust her problem-solving ability. Her identity as an Irish American appears to be a source of pride. Likewise, her strong religious beliefs and rituals sustain her.

Angela seems to be having difficulty taking in the serious- ness of her child’s illness. She continues to think that he is just a fussy, colicky baby.

Relevant Writing and Research The literature concerning social work practice with families of pediatric patients, which is anecdotal and not research based, supports the importance of developing an empathic relationship and validating the parents’ identity as parents and the decisions they have made. The ongoing assessment needs to consider the problems that existed before the child’s illness (dungan, Jaquay, Reznik, & Sands, 1995).

Goals and Interventions Assist Angela in managing the stress of Brian’s hospi-1. talization. It is important that the social worker and staff understand the stress Angela experiences in being the sole caregiver for her mother and her son. The pos- sibility of providing parking and food service vouchers and of arranging for a visiting nurse for her mother will be explored. offering these services, as needed, will be helpful in building a relationship with Angela and in enabling her to recognize that her needs are important to the staff. Assist Angela in developing a new view of her son and 2. his future, as well as her own future. The use of support and clarification will enable the social worker to pro- vide a relationship within which Angela can grieve the loss of the child she expected and develop a bond with Brian, as he is. Angela has suggested that she has con- flicted feelings about men, having been abandoned by her father and her boyfriend. If she is willing, it could be helpful to explore her feelings about men and how she imagines it will be to raise a male child in a changing neighborhood that doesn’t feel safe. The social worker will explore the ways in which having this baby derailed other plans she might have had for herself and evaluate how she is adjusting to the loss of that anticipated life.

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Support Angela’s strengths. The social worker will 3. encourage Angela’s current level of functioning by having her continue to make arrangements for the concrete services needed upon discharge, including contacting the Worcester Breast milk Bank. The social worker will encourage ongoing use of her church and friends for support. Referral to a support group for mothers of children 4. with gastrointestinal disorders. Participation in such a group might support Angela in her ongoing struggles with Brian’s care. It could also help her develop an awareness of social injustices and inequities in the health care system and help her advocate for better health care for herself and others like her. Continue to investigate research specific to helping 5. parents of children with gastrointestinal disorders. A search of the Social Work Abstracts database using the keywords “Pediatric G.I. disorders” uncovered the fol- lowing citation: Hathaway, P. (1989). Failure to thrive: knowledge for social workers. Health Social Work, 14(2). Since such disorders might initially present as failure to thrive, a keyword search using this term elic- its 37 more articles.

Treatment Relationship mindful of her maternal feelings toward Angela, the worker will be careful to empower her by not taking over. It will also be important to be curious about Angela’s experience of growing up Irish and to encourage her to express concerns about religious and ethnic differences between herself and the social worker. Showing empathy for the strain of being torn between her mother’s needs and those of her son will help Angela to feel trusting and safe; this will enable the sharing of strong feelings.

Plan for Evaluation Signs of success will include the following:

decreased anxiety and sadness could be measured by 1. depression scales at the beginning, middle, and end of the treatment. Increased comfort on the unit and trust in the staff 2. would be measured by self-reports and observations of multiple staff members. Increased comfort in managing Brian’s care would be 3. measured according to a decrease in anxious phone calls and increased instances of advocating for Brian’s care and making follow-up calls and arrangements. Increased confidence in her own judgment and efforts 4. would be evidenced by decreased requests for support from the worker and increased reports of her success- ful management of situations.

Conclusion

Every clinical situation is unique and leads to the collec- tion of information and development of a formulation specific to the particular circumstances of that situation. At the same time, the values and interests of the social work profession require a broad approach to assessment and formulation that integrates social justice, ecological, systemic, biological, cultural, spiritual, and psychological perspectives. At this time in the history of social work, there are pressures to reduce, simplify, and reconfigure the assessment and formulation process in ways that will redefine practice. We advocate a model for assessment and formulation that is broadly conceived. It contains components historically important in social work; our model reconfigures them in the light of contemporary theories and approaches. With a comprehensive model for assessment and formulation, we can sustain the rich- ness of multiple orientations and understandings that best inform our work.

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Ruth G. Dean, Phd, LICSW, is professor, Simmons College School of Social Work. Nancy Levitan Poorvu, mSW, LICSW, is adjunct professor, Simmons College School of Social Work. Correspondence regarding this article may be addressed to the first author at [email protected] or at 300 The Fenway, Boston, mA 02115.

manuscript received: march 16, 2007 Revised: december 19, 2007 Accepted: January 22, 2008