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Bryn Mawr College Scholarship, Research, and Creative Work at Bryn Mawr College Graduate School of Social Work and Social Research Faculty Research and Scholarship

Graduate School of Social Work and Social Research

1999

Social Work Assessment: Case Theory Construction Cynthia D. Bisman Bryn Mawr College, [email protected]

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Custom Citation Bisman, Cynthia D. "Social Work Assessment: Case Theory Construction." Families in Society 80 (1999): 240-246.

A M E D L E Y O F P R A C T I C E A P P R O A C H E S

Social Work Assessment: Case Theory Construction by Cynthia D. Bisman

Abstract To intervene effectively, social workers need to make sense of clients and their situations. A case theory approach to assessment pro- vides a framework to formulate assessments that are clear and directly related to the real-world problems clients present Explaining the problem situation, case theory forms the foundation for selection of intervention strategies and methods to achieve change. Build- ing case theory requires practitioner abilities to form concepts, relate concepts into propositions, develop hypotheses, and organize these into a coherent whole. Including case background information, observations and relevant professional literature, case theory pre- sents an accurate and cogent comprehension of the client Two case examples of depression illustrate the important relationship among concepts, empirical referents, propositions, general theorles, and intervention, highlighting how case theory guides practice.

AN OVERARCHING INQUIRY DIRECTS this article: How do social workers figure out what is going on with clients? Embedded within is another question: What is the point of this knowledge? I offer here a case theory framework for use by social workers to make sense of cli- ents and their situations and connect that comprehension to treatment planning and intervention.

In social work, it is the assessment that determines the nature of the client’s current situation at a particular point in time. Resulting in the product of a written as- sessment (variously called a psychosocial study, intake re- port, or social history, among other nomenclature) and entailing specific tasks such as observing and interview- ing clients along with data gathering, the process of as- sessing is often ignored. Yet, without a clear framework for thinking about and engaging in the process of assess- ment, the products will be flawed and either useless to the social worker, or harmful to the client, or both.

Through gathering data that determines the relevant attributes of each case, social work assessment provides the “here and now” and how it got that way. A far more complex and significant process than data collection, as- sessment also incorporates the tasks of deciding which data to seek and how to organize it. Moreover, all prac- tice components flow from the assessment that shapes the character of the professional relationship, impacts on communication methods and skills, directs social work

intervention, determines measurements and data collec- tion needs, and guides evaluation. As a joint activity by both the social worker and the client, assessment requires their mutual understanding and agreement. Engaged in a journey together, social workers and clients work to de- termine the nature of the problem causing the client dif- ficulty so that they can change the situation.

Assessment was an effort by Mary Richmond to make the social work profession more scientific. In her Social Diagnosis (1917), she provides a lengthy and de- tailed method for obtaining social evidence, which was used by the social worker for understanding the client’s difficulties and deciding “what course of procedure” to follow (p. 39). She states, “social diagnosis is the attempt to arrive at as exact a definition as possible of the social situation and personality of a given client. The gathering of evidence, or investigation, begins the process, the crit- ical examination and comparison of evidence follows, and last come its interpretation and the definition of the social difficulty” (p. 62).

Social work has not yet reached a consensus on the structure and function of assessment. Some in the profes- sion criticize a current trend to substitute psychodiagno- sis for social work assessment by relying on prepackaged scales such as the DSM-IV (Mattaini & Kirk, 1993; Ab- bott, 1988; Ikver & Sze, 1987). Others, like Hudson (1990), call for heavy reliance on computers and stan-

Families in Society: The Journal of Contemporary Human Services Copyright 1999 Families International, Inc.

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dardized scales, and Hopton (1998) reports on the use of psychological profiles in risk assessments.

Importance of a Case Theory Approach to Assessment

For social work assessments that are clear and directly related to the real-world problems that clients present, case theory provides a means of conceptualizing assessment and formulating assessments that are not only accurate and in- formative but also lead directly to relevant interventions. Case theory provides a set of ideas to understand and treat the symptoms or problems in functioning of one particular client (client may refer to an individual, family, group, com- munity, or organization).

Consider the following situation facing Melissa, a social worker employed for two years by a child guidance center.

The eight-year-old client, Edith, is in second grade and has been residing with her maternal grandmother for the past year along with her ten-year-old sister and two older male cousins. Edith cries often, is uncommunicative at home, picks fights with children at school, and does poorly in school work. Records show that Edith’s mother abused drugs and had several abusive relationships. Edith does not know her father, who is incarcerated.

How does Melissa understand these facts? She looks closely at Edith’s sad face and remembers information from her classes about attachment theory (Bowlby, 1977) that discontinuities of parenting can result in depression. Melissa has always been drawn to object relations theo- ry (Winnicott, 1989), which offers her a way of under- standing Edith’s problems. Melissa decides that Edith has poor social relations with others because her split be- tween good and bad was not resolved before she reached one year old and because of that she has low self-esteem resulting from lack of a supportive caregiver during in- fancy. Deciding that Edith is depressed, Melissa recom- mends weekly therapy sessions to help increase her self- esteem, utilizing play and supportive group therapy.

What do we think of Melissa’s approach to this case and how she came to an understanding about Edith? Some may worry that Melissa was too quick with her di- agnosis of depression, possibly neglecting other explana- tions for Edith’s problematic behaviors. What if, instead of struggling with issues in her past, Edith is being

abused now, possibly by her older male cousins? O r per- haps her symptoms are the result of her mother’s drug use during pregnancy? Most of us can probably agree that Melissa needs a fuller understanding to be sure she is on the right track. More information is necessary about Edith’s current home environment along with a learning assessment from the school and a current medi- cal examination. If Edith is currently residing in an abu- sive situation, she continues to be at risk without inter- vention aimed at providing her with a safe environment. Likewise, should Edith have physiological problems making learning difficult for her, targeted help from the school at this early age could prove highly productive.

Missing in Melissa’s assessment and intervention is a deliberative process of building an understanding that ac- curately explains her client’s symptoms. A case theory approach to assessment provides a structure for social workers to follow in comprehending their clients. This framework emphasizes utilization of relevant contempo- rary literature and direct focus on the empirical evidence in the client’s life. Conceptualizing assessment as case theory building enables practitioners to articulate what is happening with a particular client at one specific point in time and is essential to an intervention that is germane to that client and relevant to the presenting problem and context of the client situation.

Building case theory demands the knowledge about concepts and theory construction and the skills to relate concepts into propositions, develop hypotheses, and avoid deductive and inductive fallacies. Let us review these terms and then illustrate their use in formulating a case theory.

Theory As Bisman and Hardcastle (1999) explain, pursuit of

theory is to provide orderly explanations of the confu- sions in life experiences. In drawing patterns from obser- vations to explain phenomena, different persons may ex- plain the same events with a range of theories. The theory is not real but rather is the individual’s attempt to explain real things. They further emphasize that available tech- nologies and contemporary ideologies influence theories by discussing the contrast in theories about depression from the 1970s with those in the 1990s. Freudianism dominated the 1970s explaining depression as a primar- ily psychological phenomenon. In the 1990s pharmacol- ogy is the mode, viewing depression as a bio-chemical imbalance while gene research offers new ways to under- stand and explain the etiology of what was once consid- ered solely a “mental” disorder. They predict more rapid

FAMILIES IN SOCIETY May - June 7999

T&? idea: Labt.l: The IIlentdl The word o r p i c t u r e and words represent- L o n w w m m ot ing the idea.

\\ orld. \ o t l l t ‘ pdrt o t [he

shifts with increasing advances in technological knowl- edge.’

Constructions by individuals to order events, theories offer logical conclusions based on presented relationships. Other than final proofs of logic and mathematics, which stem from stated premises and are not from or about the empirical world, theories do not offer universal laws bur rather present different levels of abstractness (some, such as Lakoff and Nunez, 1997, believe that even abstract mathematical concepts are based on human experience).

Perhaps one of the more elegant definitions of theo- ries is offered by Karl Popper (1982) when he refers to “theories as human inventions - nets designed by us to catch the world” (p. 42), warning that “there is no ahso- lute measure for the degree o f approximation achieved - for the coarseness or fineness of the net” ( p . 47).

Whether grand, scientific, or case, theory is a sys- tematically related set of propositions that explain and/or predict phenomena (Dubin, 1978, pp. 15-32; Lewis, 1982, pp. 18, 61-63; Reynolds, 1971, pp. 10-11, 87- 1 14). While theories are not inherently “real” o r “hypo- thetical,” their usefulness as constructions increase the more they can explain and predict. Theories range through levels of abstractness from grand theories that explain a lot of phenomenon to very concrete and cir- cumstantial case theories that are locked in a specific time, place, and event. Freudian theory offers explana- tion of all human development and behavior and is an example of a grand theory. Good case theory provides understanding of the case, explaining why a particular client is behaving in a certain manner, laying the foundci- tion for prediction of interventions necessary t o accom- plish the case objectives and case change.

%e &h€: The thing in the world captured by the idea.

Concept Formation Case theory building requires specification and de-

velopment of concepts - the fundamental units and building blocks of propositions and theories. For practi- tioners to understand the meaning ot case theory, they must understand the theory’s concepts. Ideas in the mind. concepts are the words or labels symbolizing the external things that the ideas represent. Just as we discussed with theories, concepts are not reality but represent a mental construction of realit!..’

The mental and empirical processes of developing and operationalizing concepts and relating the concepts t o explain and predict things is theory building. I’racti-

tioners must relate concepts in case theory t o each other. I t the case theory building is faulty, interventions based on the theory are not likely to produce the intended re- sults and may result in harm.

I Jnderstanding concept starts with three components illustrated in Table 1 below: I . The idea or mental image and construction in the

2 . The words or labels symbolizing the idea, and 3 . The external thing, phenomena, and empirical refer-

ents in the world represented by the labels.

mind.

Table 1.

I Child abuse 1 I !

Conceptualization is the process of assigning words to ideas, abstractions, and constructions of empirical re- slit!- that have empirical references. Practitioners must not reify the concept by assuming that the idea is real or the only construction of reality. It is also important to de- \,rlop the nominal detinition and domain of the concept t u distinguish empirical referents that fall within the idea trom those that do not. Operational definitions that cap- rurc the idea are prerequisite to concepts that are usable i n c ~ s e theory.

Propositions and Hypotheses Theories are composed of propositions, which are

statements about the relationships among elements, con- cepts, or attributes of one or more concepts. Propositions allow us t o understand concepts and relate and integrate them into theory. The task in building and reviewing the- ory. including case theory, i s to find the “if-then’’ propo- <itions that constitute the theorv to explain the case and provide prediction for the appropriate intervention.

Hypotheses are propositions that are capable of em- pirical testing but as yet are untested. One function of re- Fearch is to test and establish the validity of hypothetical propositions. Deduced from theorv or induced from em-

‘ The following sections ovi theory draw from Bismm and Wilrdc-astle, 1 9 9 9 . chapter four. ‘Blumer’s ( 1 9 6 9 ) i i w k O I Z symbolic interactionism influences thesc ideas.

Bisman Case Theory Construction

pirical generalizations and experiences, their purpose is to extend the explanatory and/or predictive capacity of theo- ry or to explain empirical generalizations and experiences.

Deduction and Induction Deduction is moving from a theory’s general propo-

sitions to application of these propositions for the pur- pose of offering an explanation of the specific case.

The reasonableness of the hypothesis, the deduction,

General: (If) biological factors such as genetic family his- tory and social factors such as social isolation contribute to depression. Specific: (If) individuals such as Mia Hanes have a genetic family history of depression and are socially isolated, (then) Mia Hanes’ depression may be explained by and treated through physical and social factors such as medication and increased social support.

depends on (1) the validity or truthfulness of the general theoretical propositions from which the hypothesis was deduced, (2) whether the specific case falls within the class of cases covered by the theoretical propositions, and ( 3 ) its capacity to guide the intervention hypothesis for this specific case. Do biological theories and social isola- tion explain depression? Is Mia Hanes’ depression ex- plained by her biology and social isolation? If the answer to either is no, then the hypothesis that “Mia Hanes’ de- pression is explained by and treated with medication and social supports” is neither logically deduced nor empiri- cally supported.

In induction, observations lead to analyses of pat- terns out of which propositions emerge to explain those patterns. Steps for observations necessary in inductions include: 1) examine a representative sample of socially isolated persons who also have a genetic family history of depression for patterns of the relationships between de- pression with social support and genetic family history; 2 ) explore whether increased social support and medica- tion results in reduction of depression for these persons. If the pattern indicates that there is a reduction, then we can formulate the induction: medication and social sup- port help reduce depression. For the above situation we are ready for the “if-then’’ proposition.

Specific: (If) examination of specific cases of persons with depression share factors other than depression such as social isolation and genetic family history and (if) per- sons without depression do not share these factors. Gen- eral: (Then) the factors of social isolation and genetic family history are associated with depression.

Here, the reasonableness of the general proposition from the induction, depends on (1) representativeness of the sample of depressed and nondepressed persons and ( 2 ) presence of and observations of the factors within these samples. Do these persons share genetic family his- tory and social isolation? Do other persons in the popu- lation share these factors who are not depressed? If the answer to either is no, then the hypothesis that social iso- lation and genetic family history are associated with de- pression is not empirically supported.

Fallacies Deduction from general propositions to a specific

case and induction from limited experience in research and practice to all cases can impede practice through de- ductive and inductive fallacies. Most social science theo- ries describe characteristics of the general case or group. They are not laws covering all cases, a particular case, or even any case, within a class or group. One commits a deductive fallacy when assigning the attribute of a group or class described by a general theory to a specific case within the class, but the case does not contain the at- tribute. Assuming that a trait of all adults who were abused as children is to abuse children, and then inferring a particular client who was abused as a child is abusing her children, is commission of a deductive fallacy.

Conversely, an inductive fallacy is wrongly assuming that the trait of an individual case within a group applies to all or any other case in that group, if they do not share the trait. Social workers over relying on practice wisdom, limited case experience, or research with inappropriate, inadequate, and unrepresentative samples in building case theory are likely to commit inductive fallacies. For example, a social worker is treating four clients who share a common problem - they each have bulimia. In obtaining family history, this worker discovers that each client was an incest victim. Concluding that incest causes bulimia, the social worker ascribes a trait, “incest vic- tim,” to a group, “those who have bulimia.” In commit- ting this inductive fallacy, the practitioner erroneously generalizes from the four specific cases to a larger group. Incest is not a trait of all those who have bulimia nor do most incest victims become bulimic. The few cases do not adequately represent the larger group.

Case Theory Construction in Practice If successful, case theory accounts for the phenome-

na of this one case, but does not prove the general theo-

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ry for classes of persons. A construction of social reality, case theory is the meaning attached by the social worker to the client’s narrative and other gathered information, leading to shared construction of a new reality for the cli- ent, reflected in the intervention.

General and Case Theories Practice without case theory leaves practitioners rely-

ing on the general theories of behavior, which are usually too broad to be of much use in adequately understanding a specific client or are dependent on loosely formed hunches that may relate more to their own instincts than to empirical data. Faulty case theories are also harmful. Drawing from the wrong general theories, they provide information that is not relevant and may even be danger- ous to the client.

Social, psychological, and behavioral theories includ- ing systems and exchange theory, psychodynamic, oper- ant, social learning, and cognitive theories do inform case theories. Nevertheless, they are quite different. These con- ceptual models are nomothetic, which means they apply to groups of persons while case theories are idiographic. As Bisman states, “By definition, if the case theory fits this individual case, it will totally fit no other client situation” (1994, p. 117). A central feature of case theories is their use of these general theories to provide support from a wide body of professional research and scholarship.

Case theory determines which of these general theo- ries or professional literature to choose. Rather than one particular theoretical model driving all practice decisions, a case theory approach requires knowledge of multiple theories and the ability to utilize a framework that best re- lates to the circumstances of a specific client. This may be clearer when we think of a medical situation. We would not expect a specialist in gastrointestinal disorders to di- agnose all problems as intestinal, but rather to rely on a thorough medical examination and remain open to a range of explanations for the patient’s problems. Prescrib- ing medication for pain resulting from gastro reflux can result in great (even deadly) harm if the patient’s pain is instead from angina and heart attacks go untreated.

Furthermore, for fully developed and valid social work case theories that adequately address the breadth of the social work domain, social workers need to use bio- psycho-social models, including biological information of genetic content and physical attributes, psychological data covering the intrapsychic and personality factors, and the social information about range and type of com- munity and social supports and resources with their avail- ability to the client.

These differ from the (1) bio-psycho-medical theories of human behavior that present behavior as the result of the individual’s biological and intrapsychic content, whether due to genetic content or early socialization, (2) educational theories that view behavior and management of social relations and the social environment as learned or conditioned, and ( 3 ) psycho-social theories that inter- pret behavior as a function of the individual’s psycholog- ical content in interaction with the social context.

It is not unusual, however, for practitioners to skip the process of formulating such an understanding for each of their clients and instead solely rely on general concepts, such as depression or alcoholism. A basic assumption, however, in utilization of diagnostic categories is a shared understanding of these phenomena. Yet as we discussed earlier, these concepts are not real but rather refer to em- pirical events. Accordingly, knowledge of these specific circumstances is necessary to understand each individual client’s depression or substance abuse in order to plan an intervention that relates to that particular client’s real-life circumstances. This is particularly important because there are many general theories explanatory of concepts such as depression and alcohol abuse. Moreover, with in- creasing reliance on the growing number of DSM IV cat- egories, it is essential to clarify the meaning of the diag- nosis. Just as physicians must provide specificity when diagnosing cancer or heart disease, social workers must identify the attributes of their diagnoses.

Case Example and Case Theory Let us consider another example and examine the so-

cial worker’s approach to building a case theory. Based at an urban community mental health center

which provides services to any residents, the social work- er, Janet, meets with Rosie, a forty-five-year-old Latino woman. Currently unemployed, Rosie completed tenth grade and has held various jobs, usually as a sales clerk. She lives with her twenty-five-year-old daughter, has lit- tle interaction with her family, and keeps very few friends. Rosie came into the session complaining that she feels sad and has little energy. When Janet pushes for specificity, she learns that Rosie often sits around the house all day doing nothing, sleeps about twelve to four- teen hours, watches TV about six to eight hours, and is losing weight because she does not eat very much. Janet asks how long she has felt this way and learns that Rosie has had these bad feelings on and off since her early teens, when she used to think of killing herself. These thoughts often alternated with great bursts of energy when Rosie felt wonderful. Asking how it is that she is

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now asking for help, she learns Rosie feels worse since testing positive for HIV, three months ago.

Janet formulates the following case theory:

Rosie’s recent HIV diagnosis is exacerbating her long term social isolation and possible clini- cal depression. Goldstein (1995) and Jue ( 1 994), indicate that stigma from AIDS often socially isolates these patients, while Mancoske (1 996) points to their greater risk of suicide. In- dividuals need an active energy exchange with others as Greene ( 1 991) explains in her discus- sion of systems theory, and for a long time Rosie has had no person with whom she can talk openly. Her long history of severe mood swings suggests bipolar disorder. Evidence supports a biological basis for treatment of depression (Sperry, 199.5). Jensen (1 994) points to a p s y - chosocial perspective combined with a biologi- cal perspective.

Because she knows we can use the concept of depres- sion to describe different conditions, Janet identifies the empirical indicators relevant for each client labeled as de- pressed. The empirical behaviors for Rosie include the following problems: sleeps an average of thirteen hours per day, shows a decrease in appetite, has severe mood swings, and an overall lack of functioning with extensive

Developed from data collection and observations, case theory presents social workers’ understanding of a particular

client‘s problematic condition at a specific point in time.

periods of sitting around and watching television. Propositions in Janet’s case theory pose a

relationship between social isolation, illness, biology, and depression. Janet’s hypothesis is a deduction that Rosie’s symptoms are explained by her biology, social isolation, and disease. Correspondingly, Janet refers t o general the- ories of systems, biological and psychological, and social explanations for understanding depression and the psy- chosocial effects of AIDS.

Emerging from this case theory, Janet’s intervention in- cludes both increasing social supports and a medical con- sult to consider pharmacology for the possible bipolar disorder. Focus on just AIDS, or only the social isolation, or solely the clinical depression ignores important vari- ables. Janet is aware that any of these narrow interven- tions is potentially harmful to Rosie.

When we compare Janet’s approach to understand- ing Rosie with our earlier example of Melissa, we can see the enhanced practice by Janet who is able to directly link this understanding to her intervention based on concrete evidence. The clear statement of her case theory’s propo- sitions and hypotheses and identification of the general theories she uses prevent fallacies in her thinking. By broadly basing her case theory to incorporate multiple hypotheses, she logically draws from a range of general theories resulting in a plan of intervention that addresses the breadth of social work practice by including biologi- cal, psychological, and social factors.

Summary

In response to the initial questions of how social workers make sense of clients and what they do with that information, we have examined a case theory approach to social work assessment requiring comprehension of theory, specification of concepts, and development of propositions and hypotheses. Emphasis is on the linkages between building a theory of the case with accurate client assessments and relevant subsequent practice interven- tions. While recognizing the importance of case theory constructions by practitioners, this framework also dis- tinguishes case theory from those general theories found in the literature.

Case theory, like all theory, is explanation of phe- nomena. Idiographic, case theory applies only to a spe- cific case and is distinct from social and behavioral theo- ries, which are nomothetic and apply generally to groups of persons. Developed from data collection and observa- tions, case theory presents social workers’ understanding of a particular client’s problematic condition at a specif- ic point in time. As Florence Hollis (1970) stressed in her development of the psychosocial approach, the purpose of assessment is to develop the basis for treating each cli- ent as a separate individual. Addressing specific empirical events, the test of the case theory is the extent to which it explains this unique client, accounts for the phenomena, and guides a successful intervention. Case theory con- nects this client’s past to the present and future in order

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to project a future set of events - the change in the cli- ent’s presenting problems (Bisman, 1994).

Social workers must consider and confront both social context and individual content of behavior and ac- cordingly rely on bio-psycho-social theories where behavior is a function of the individual client’s biological and psychological content and the social context - the social work domain.

Social work practice involves using and testing theo- ries. To formulate their assessments, social work practi- tioners require theory-building knowledge and skills. Building case theory requires practitioner abilities to form concepts, relate concepts into propositions, develop hypotheses, and organize these into a coherent whole. From case theory’s coherent explanation of the empirical referents and reference to general theories and wide pro- fessional knowledge, come selection of intervention strategies with methods to change the presenting prob- lems. Including client background information and perti- nent professional literature, case theory presents a cogent and valid comprehension of the client, a prerequisite for appropriate interventions that are helpful to clients.

Jensen, C. (1994). Psychosocial treatment of depression in women: Nine single-subject evaluations. Research on Social Work Prac- tice, 4, 267-282.

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Mancoske, R. (1996). HIV/AIDS and suicide: Further precautions. So- cial Work, 3, 325-326.

Mattaini, M., & Kirk, S. A. (1993), Points and viewpoints: Misdiag- nosing assessment. Social Work, 38,231-233.

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References Cynthia D. Bisman is associate professor, Bryn Mawr College, Graduate School of Social Work Bryn Mawr, PA.

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Author’s note: The author acknowledges thefollowing Bryn Mawr MSS studentsfor their case material: Jacqueline Stahl and Janine Wettrtone.

Original manuscript received: July 1, 1998 Revision received December 28, 1998 Accepted: January 1, 1999

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