Unit 7 DB: Information Overload

The Case File

· Describe the reasons why the case file is important.

Medical Information

· Tell how medical information contributes to a case.

· Decode medical terms.

Psychological Evaluation

· List the reasons for a psychological evaluation.

· Make an appropriate referral.

· Identify the components of a psychological report.

· Review two psychological reports.

· Describe the type of information provided by the DSM-5.

Social History

· State the advantages and limitations of a social history.

· Name the topics included in a social history.

· List the ways social information may appear in the case file.

Other Types of Information

· List the types of educational information that may be gathered.

· Define a vocational evaluation.

· 9-1Introduction

· —Case manager, services for children and families, New York, New York

· Our shelter provides mid-term shelter. A few shelters only provide lodging and services for 4 nights. We allow our clients to remain with us for up to 30 days. Other shelters’ clients have to commit to a year of residence. For our month, we provide clients with a wide range of services. We try to meet all of their needs. Comprehensive assessment is key, and we provide an on-staff psychologist, group counseling, and individual and family work.

· —Director, emergency shelter, St. Louis, Missouri

· When a child is referred to our agency, we immediately seek more information. For example, the first thing a case manager does is contact the school and ask for records. Of course we have a release from the parents to get the records…. We need the school records even if the child is referred for a medical issue.

· —Care manager, high school, Los Angeles, California

· The chapter-opening quotations illustrate the kinds of information that a case manager may need from other professionals to develop a plan or to provide services. The medical information, histories, or exams these three helpers mention are part of the case files of clients who have medical problems. The case manager providing services for children and families speaks of the advantages of being familiar with medical terms and medical references when trying to decipher medical reports. Physical assessments and psychological assessments offer important information to the emergency shelter staff as they work with homeless and runaway female teens. Professional staff at the high school in Los Angeles gather much information about the students from other schools.

9-1aThe Purpose of the Case File

Finally, agencies are committed to provide quality care to their clients. Part of that quality of care includes effective responses in times of crises and efficient transition of services as practicing case mangers leave the organization and new staff assume the responsibilities of those leaving. An in-depth case file allows new case managers to establish rapport with and understand their clients and where they are in the case management process.

In summary, the case file directly addresses the critical nature of two facets of case management, that of working with the whole person and that of providing documentation and maintaining good records. This helps in the process of service coordination. Careful attention while building the case file is important for several reasons, including legal accountability, financial and outcome accountability, and effective client services.

The purpose of building a case file shifts during the case management process. For example, when an individual is applying for services, the case manager begins to build a case file to determine if the individual applicant is eligible for services. Once eligibility has been established, the information previously gathered becomes the foundation and provides the initial data for that file. During the case management process, additions are made to the file. These additions may include:

· a)

further assessments;

· b)

the case management plan;

· c)

case manager written case notes;

· d)

periodic assessments of the case management plan and process; and

· e)

revisions of the case management plan.

At the end of the case management process, added to the case file are:

· a)

reasons for ending client services;

· b)

final outcomes;

· c)

plans for client aftercare;

· d)

plans for follow-up;

· e)

client evaluation of services; and

· f)

case manager evaluation of services.

Agencies approach medical information in different ways. Some require documentation of a mental or physical disability or condition when determining eligibility for services. Others use a medical examination as part of their assessment procedures. In certain situations, medical information is not gathered unless there is some indication or symptom of a disease, condition, or poor health that would affect service delivery.

Medical knowledge is particularly crucial when working with people who have disabilities. A general medical examination and specialists’ reports help determine the person’s functional limitations and potential for rehabilitation. It is important to set objectives that are realistic in light of the client’s physical, intellectual, and emotional capacities. When a medical report covers a disability in functional terms:

[I]t addresses the following factors [and] the description can read like the following: strength, climbing, balancing, stooping, kneeling, crouching, crawling, reaching, handling, fingering, feeling, talking, hearing, tasting, and smelling, near acuity, far acuity, depth perception, visual accommodation, color vision, and field of vision. (Debates, Rondinelli, & Cook, 2000, p. 81)

Each medical evaluation includes recommendations relating to the individual’s physical, emotional, and intellectual capacities. What follows is a sample medical recommendation.

The individual has a diagnosis of obsessive-compulsive disorder and has limited strength, balancing, hearing, and near-acuity functionality. This person needs work with supervision, few stressors, and limited lifting.

Often, however, the form for a general medical examination allows only a small space for the diagnosis, so the case manager reads a phrase such as “chronic back pain,” “normal exam,” or “emotional problems.” Not very helpful, is it? Remember that the client is an important source of information; he or she can tell you about any problems. You may then need to decide whether or not a specialist’s evaluation would be helpful.

It is important when referring a client for a medical exam that the case manager prepares the client for that experience. This is especially critical from the multicultural perspective. For many individuals, the medical establishment represents a place where they have little knowledge, no power or authority, or have had previous difficult experiences. Many case managers find that the best resource for culturally sensitive physicians is the client himself or herself. When you follow-up on a medical referral, you can ask clients about their experiences.

Voices from the Field

Conducting Culturally Sensitive Medical Exams

An approach to medicine that is client-centered is important. The University of Washington (2009) uses guidelines to educate and train their medical students regarding how to conduct an interview. The guidelines that follow provide case managers with specific ways they may assess the sensitivity of the physicians conducting the medical exam.

· “Appreciating the ethno-cultural, spiritual, and religious perspectives of patients, families, and communities. … The term cultural humility, coined by Tervalon and Murray-Garcia (1998), expands this to include the recognition of power dynamics in health care and the community at large and encourages physician advocacy to address imbalances” (p. 77).

Goals of culturally sensitive medical interviewing and their responsibilities related to each follow.

· Demonstrate contextual sensitivity and use cultural sensitivity. Be aware of family, cultural, and religious values and the influences of gender, age, socioeconomic status, and education level.

· Gather information regarding patient and family perspectives on, and use of, traditional and/or complementary healing strategies.

· Exploring and understanding the approaches patients have used in treating their illness is very important.

· Eliciting this type of information may be challenging. Historically, some patients and family members have been misjudged and even chastised by healthcare professionals for admitting use of alternative or traditional remedies.

· Be cautious and sensitive when trying to elicit this important information.

· Be attentive to any verbal or nonverbal cues that the patient may be uncomfortable discussing alternative healthcare practices (i.e., silence, eye deviation, a shift in their seated position, crossing their arms, etc.).

· Questions such as the following may be helpful to ask:

· Have you seen anyone else about this problem besides a physician?

· Who do you think gives you good health advice?

· Who else do you trust?

· Have you participated in any healing practices or ceremonies to treat your problem?

· Have you used nonmedical remedies or alternative or traditional treatments for your problem?

· What role do they serve in your care?

· Who in your family or community advises you about this condition?

· How common is this condition in your family and/or community?

· What is done commonly to heal this illness?

The University of Washington suggests a model to guide the cultural sensitivity of the physician during the medical exam.

· Beliefs about health (What caused your illness/problem?)

· Explanation (Why did it happen at this time?)

· Learn (Help me to understand your belief/opinion.)

· Impact (How is this illness/problem impacting your life?)

· Empathy (This must be very difficult for you.)

· Feelings (How are you feeling about it?)

9-1cMedical Exams

Class Discussion

Using Culturally Sensitive Guidelines for Exams and Reports

Sharon Bello, Entry 9.1

I feel like I have been involved with doctors for such a long time. Between my dad dying, having kids, losing two sons, having my car accident, having two surgeries to try to fix my back after my accident at the senior center, and now needing more medical information to receive rehabilitation services, all of this doctoring and reports, well, it just seems like a lot. For my case management services, if you remember, Tom Chapman asked me to get a letter from Dr. Alderman about my surgery. And I had a long appointment with Dr. Brown for my physical exam. Tom prepared me well for that exam. I knew why I was going and I also knew what to expect.

This is the first time that I have ever read an actual doctor’s report. I contacted Dr. Brown’s office 2 weeks ago to let him know that reading it was important for a project I was involved in. Dr. Brown thought reading the report would be a good idea.

The written report looks different from just participating in the examination and answering questions. I remember, at first, I was afraid that something during the exam would happen and then I would not be able to receive the services. But that didn’t happen. Still, when I read the report, there are a lot of words that I didn’t know and didn’t understand.

What it does look like is that I am fairly healthy. It is just the state of my back that is giving me trouble but, well, that pain when I move is enough for me. Honestly, how my back is, it influences me every day. I guess when the doctor said that I am limited in all ways of moving, he was telling Tom how bad some of my life is for me. And when he said that there was no way to improve my back beyond what has been done, that pretty much sums up what I know and explains why I sometimes feel like giving up.

I also saw that Dr. Brown indicated that I was showing ways that I am depressed. Dr. Brown told me that he sees depression differently than most other doctors. I am not sure that I understand what he meant. He says I could have trouble getting out of bed in the morning and cry several times per day when I think about my boys. He says those signs might be just a normal reaction to very difficult experiences. And that might be different than actually having a diagnosis. He thinks a psychologist or psychiatrist might have to figure out if I have depression.

9-1dMedical Terminology

How does a case manager make a good psychological referral? First, it is important to be clear about the reason for referral. The case manager must clarify the need to document a condition or disability, obtain test scores, or explore behavioral inconsistencies. Specific questions also help the psychologist focus on the client’s problems. The psychologist then makes recommendations to the case manager. The two professionals can discuss the case before the evaluation to clear up any questions or needs. Because many referrals are made by phone or direct personal contact, such a discussion can easily take place, but it may be even more important when the referral is made in writing.

Part of making a successful referral is preparing the client for the psychological evaluation. To do this, the case manager needs a clear understanding of the process and the ability to explain it to the client. Some clients may be suspicious of testing or may fear that the case manager considers them crazy. Demystifying the evaluation helps to dispel these attitudes.

9-1gThe Process of Psychological Evaluation

The evaluation itself includes a study of past behavior, conclusions drawn from observations of current behavior, a diagnosis, and recommendations. This study requires the psychologist to assess which data are important to the client’s presenting problems. In some cases, relevant information is in the client file; it is then helpful for the psychologist to have access to these documents in addition to the observations and questions from the referral source.

Usually, the content, sources, and format of narrative psychological reports follow a similar pattern. There are three components to the content of a report. One is the orienting data, which includes the reason for the referral and pertinent background information, such as age, marital status, social history, and educational record. Illustrative and analytical content is the second component; here, one finds the interpretation of raw data, including test scores. The third component, the psychologist’s conclusions, includes a diagnosis and recommendations, which are presented with supporting evidence. The sources of the information in all three components are the interview between the psychologist and the client; test data; behavior observed during the evaluation; any available medical reports and social histories; and any observations, case notes, or summaries written by other professionals involved with the case.

Among the headings that organize the report are “Reason for the Referral,” “Identifying Data,” and “Clinical Behavior.” Under such headings one would find the reason for the assessment, identifying information, any social data, and the psychologist’s observations of behavior during the evaluation. The subsequent headings—“Test Results,” “Findings,” “Test Interpretation,” or Evaluation”—may be subdivided into intellectual aspects (e.g., an IQ score and what it means) and personality (e.g., psychopathology, attitudes, conflicts, anxiety, and significant relationships). The diagnosis section presents the main evaluative conclusions, usually expressed as a series of numbers followed by the name of a disorder or condition.

The following background information was obtained via a background questionnaire completed by Jaden’s father. Jaden is a 5-year-old male who is in kindergarten at a Livonia County school. He currently lives in Livonia County with his parents. He also lives with a sister who is in second grade, and a brother who is 2 years old. While English is the primary language spoken in the home, Mr. Clark is fluent in Spanish and is teaching the children the language. In his free time, Jaden enjoys playing outside, building Legos, riding his bike, and watching TV.

Developmental and Medical History: With regard to medical history, Jaden was born full-term, weighing in at 7 pounds, 15 ounces. Jaden aspirated upon birth and was held in the NICU for 24 hours, began formula at 5 months, and had tubes placed in his ears at 2 years old. Mr. Clark reported that Jaden met his developmental milestones within the normal time frame. Mr. Clark reported no history of accidents or head injuries during Jaden’s childhood and reported that he was a relatively healthy child. No family history of learning or attention problems was reported.

Mr. Clark reported that Jaden is a very healthy eater and reported no history of familial alcohol or substance abuse.

Social Emotional History: Mr. Clark did not report Jaden experiencing traumatic events in the past. In terms of attention, Mr. Clark states that Jaden displays difficulty remaining on task for long periods of time and is easily distracted during activities that do not maintain his attention or interest. At times, Mr. Clark claims that Jaden is impulsive and will engage in conversations as a form of task avoidance. However, Mr. Clark stated that he believed this behavior to be exploratory in nature and that it has caused no issues in the school environment.

Academic History: With regard to his educational history, Jaden is currently in kindergarten. Jaden has never been retained or skipped any grades in school. He has never participated in special education programming. Mr. Clark reported no academic concerns at this time.

Relevant Test Behaviors:

Jaden’s testing took place in his home on a Saturday afternoon. Testing took place at the kitchen table, with adequate lighting. The kitchen was at a comfortable temperature for Jaden and did not seem to affect the testing.

Jaden wore shorts and a t-shirt during the testing session and appeared clean and put-together. He appeared to be in a pleasant mood for the testing session and was very friendly and talkative. During testing, Jaden took a break to use the restroom and talk with his mother. He concentrated in small bursts but was very persistent during the test. On a few occasions, he became frustrated when a problem was too difficult and asked if he could quit. Jaden engaged in conversation with me as a way to avoid the task at hand on several occasions. Overall, he seemed focused when determining the answers but off task in between subtests. Based on my assessment of the testing conditions, it is my estimation that the testing conditions were good and the assessment results are considered an accurate reflection of Jaden’s abilities at this time.

Assessment Results:

Please refer to the Appendix for specific results

I. Current Academic Achievement Wechsler Individual Achievement Test, Third Edition (WIAT-III)

Jaden’s academic skills within the areas of math, reading, and writing were measured using the Wechsler Individual Achievement Test, Third Edition (WIAT-III). His performance across each academic area is detailed here.

Reading. Jaden’s overall reading skills are considered average. Jaden’s scores on measures of early reading skills are average. Jaden excelled at tasks involving letter group sounds and rhyming and experienced difficulty with tasks involving selecting words ending in the same sound.

Writing. Jaden’s overall written expression skills are in the average range. Jaden scored in the average range on a measure of spelling skills. During the alphabet writing fluency task, where Jaden was asked to write as many letters of the alphabet as he could in 30 seconds, Jaden appeared distracted and attempted conversation with the examiner instead of writing down letters.

II. Current Social/Emotional/Behavioral Functioning Behavioral Assessment System for Children, Second Edition (BASC-2)

Jaden’s behavioral, social, and emotional functioning at home were measured using the Behavioral Assessment System for Children, Second Edition (BASC-2). Rating scales were completed by Jaden’s father. The BASC-2 includes several validity scales to provide an estimate of how accurate the rater’s responses are overall. Validity measures include indicators of “faking bad,” inconsistent responding, and patterned responding showing inattention to item content.

Parent Report

The BASC-2 parent report includes an overall measure of problem behavior, the Behavioral Symptoms Index (BSI). The BSI includes scales of aggression, hyperactivity, withdrawal, depression, attention problems, and atypical behaviors. Mr. Clark reported Jaden’s overall problem behaviors to be average compared to his peers; however, his Hyperactivity Scale is clinically elevated, which suggests that Jaden may tend to be overly active, rush through work or activities, or act without thinking.

The Externalizing Problems Composite measures more overt behaviors like aggression, hyperactivity, and conduct problems. On this composite, Mr. Clark reported Jaden to have an elevated level of hyperactivity when compared to his same-age peers.

The Internalizing Problems Composite is a measure of behaviors that are not readily seen, like anxiety, depression, and somatic (physical) symptoms. On this composite, parent-rating results indicated average levels of anxiety and somatic symptoms when compared to his same-age peers. Although Mr. Clark reported Jaden’s depression level to be at risk, there was not a clinically significant difference between Jaden and his same-age peers.

The BASC-2 includes an Adaptive Skills composite that measures skills needed to function independently, like adapting to changes in the environment, leadership skills, social skills, and daily activity skills. Jaden’s overall adaptive skills at home were rated as average when compared to his peers. Mr. Clark rated Jaden’s activities of daily living skills as average, meaning that Jaden is able to organize chores or other tasks well and follow regular routines. He rated Jaden’s ability to adapt to changes in the environment (adaptability), his ability to express his ideas clearly and communicate in ways that others can easily understand (functional communication), leadership, and his ability to interact appropriately with others (social skills) within the average range.

Summary and Recommendations

Jaden is 5 years old and in kindergarten at a Bradley County School, with no previously reported educational diagnoses. Results of Jaden’s achievement abilities revealed average achievement. Jaden’s scores on broad measures of reading, writing, and math are average when compared to other individuals his age. Jaden’s BASC-2 Parent Form composite-scale scores were elevated for inattention/hyperactivity. Specifically, Jaden scored in the clinically significant range for hyperactivity, which indicates that his hyperactive behavior is pervasive and at a level that could result in behavior problems.

Based on the results of this assessment, recommendations will be made to improve hyperactivity and attention.

To help with attention and organization:

· Jaden’s parents and teachers should create checklists or to-do lists for Jaden to fill out as he completes projects, assignments, and chores. Checklists may be visual or written. Checklists should also split larger tasks into smaller subtasks. Similarly, his parents and teachers are encouraged to divide assignments into shorter parts and allow Jaden opportunities to have small breaks while working.

· Jaden’s teachers are encouraged to send home daily behavior report cards. Behaviors recorded may include completing assignments during independent seat time, asking for help or a break appropriately, filling in his planner, or checking his work. To reinforce behaviors, his teacher may have Jaden choose daily and weekly rewards if he increases and/or maintains goal behaviors.

· Prior to beginning a task, Jaden should be asked to think about what will be needed to complete it, including the materials needed and also all steps necessary for task completion.

· Provide Jaden a “to-do” list or a schedule of daily classroom activities to tape onto his desk (or somewhere visible). Help model how to check or cross things off as they are completed.

Strategies to Improve Hyperactivity:

· Provide breaks for exercise or movement. Jaden may exercise upon completion of a task. Designate a spot in the classroom where he can go, away from others, to do some brief exercises, such as jumping jacks. To make this break a class-wide activity, consider playing a round of “Simon Says” with the students. They can stand next to their chairs or stand in a circle in the classroom as you play.

· Provide Jaden a “fidget toy,” such as a squishy ball, to keep his hands busy in a nondisruptive manner when a task does not require the use of his hands. Make sure Jaden understands the rules; if the toy becomes a distraction in itself, you will take it back.

Wechsler Individual Achievement Test, Third Edition (WIAT-III)

WIAT-III Composite Scores

Note: Composite scores have a mean of 100 and standard deviation of 15.

WIAT-III Subtest Scores

Note: Subtest scores have a mean of 100 and standard deviation of 15.

Behavior Assessment System for Children, Second Edition (BASC-2)

Mr. Clark completed the parent version.

Note: T-Scores have a mean of 50 and a Standard Deviation of 10.

This report was prepared by Victoria VanMaaren and used with permission.

The DSM-5 (American Psychiatric Association, 2013a) presents information and diagnostic material in three sections. The first section introduces the manual and describes guidelines for its use. The second section presents the 20 categories of diagnoses. The third section describes additional ways to assess clients. For example, there are multiple online instruments to help clinicians view clients in more holistic ways. A cultural interview guide is included and helps clinicians better understand how client culture (such as culture, race, ethnicity) influences mental health (American Psychiatric Association, 2013a). These assessments and interview guides in section 3 help involve the client and gain his or her perspective in the diagnosis and assessment process.

Class Discussion

Comparing Two Psychological Reports (Child and Adult)

Duncan also fits the profile of a person with unspecified depressive disorder. Although he exhibits a “blue” or low mood, Duncan does not report significant appetite or sleep disturbances, or anhedonia. In addition to not fully meeting the criteria for major depressive disorder, it is unclear whether his current depressive mood state is caused solely by his grief of the loss of his girlfriend (i.e., bereavement). His traumatic event seems more severe than typically found in an adjustment disorder. Furthermore, there is evidence in the empirical literature that trauma often induces states of depression, further complicating the clinical picture.

Duncan seems to meet the criteria for alcohol intoxication rather than an alcohol use disorder, because the frequency, duration, and intensity of his alcohol use is unknown at this time. An alcohol use disorder could be ruled out. Other conditions that may be the focus of clinical attention include Duncan’s threat of losing his job due to dissociative episodes, diagnosed in DSM-5 as other problem related to employment.

Further and ongoing assessment will be necessary to rule out major depressive disorder. This diagnosis should be considered because of his low mood and cannot be ruled out at this time because the etiology of his low mood has not been determined. His alcohol use should also be evaluated and carefully monitored; it is possible that Duncan has an alcohol use disorder that may be exacerbated following the recent traumatic event. Any substance use would affect his prognosis by stalling treatment. Furthermore, medical causes of his symptoms, such as a closed head or traumatic brain injury, should be ruled out. Neurological testing and/or CT scans seem to be indicated.

Additional information that is important to keep in mind to best understand Duncan is that he had been dating the girlfriend who died in the MVA for 3 months. He has no history of drinking-related driving arrests, and prior to the accident he only had a few points on his current driving license for speeding.

Theoretical Approach

Regarding treatment needs, Duncan currently seems to meet the criteria for outpatient service level on the continuum of care. He may need higher-frequency (e.g., twice weekly) sessions to begin to stabilize some of his most prominent symptoms. A more intensive level of care is not indicated at this time because Duncan is not suicidal or homicidal, and he seems to be functioning to the degree that he can sustain his current employment (albeit tenuously).

The theoretical approach that this client would most benefit from is trauma-focused cognitive behavioral therapy (TF-CBT). This approach is likely to be successful because Duncan’s symptoms of trauma need to be reduced for Duncan to meaningfully attend to other important areas of his treatment. This would also prevent Duncan from losing his job due to his inattention, which is hypothesized to comprise dissociative episodes.

Initial Interventions

Initial interventions include writing a trauma narrative, being trained in relaxation techniques, and processing his narrative using subjective units of distress (SUDS) scaling. These interventions directly target PTSD symptoms and are consistent with TF-CBT. Once Duncan has managed to mitigate his immediate suffering, deeper themes can be addressed. These include grief, loss, and guilt from his choice to drink while driving on the night of the MVA when his girlfriend was killed. Furthermore, Duncan’s avoidance of interpersonal contact with others for fear of harming them needs to be addressed.

Transference and Counter-Transference

Legal and Ethical Concerns

Some potential legal and ethical concerns that may arise in this case include the potential for Duncan to request me as a character witness if he is called to court to face charges for his MVA (and potentially a DUI charge). The basics of confidentiality, informed consent, disclosure of services provided, and fee arrangements will need to be addressed from the outset. In addition, I will use consultation and supervision to ensure I am receiving any additional support while providing TF-CBT in a fairly complex case; I will be mindful of practicing within my bounds of competence and seeking assistance when needed.

It is hoped that with increased support, Duncan’s distress will diminish so that his sense of right and wrong, care for others, and sense of personal responsibility can lead him along the path of optimal development.

Part II. Diagnosis and Treatment Plan

What Problem Behaviors/Symptoms Does This Person Exhibit?

1. Dissociative episodes

2. Psychic numbing and avoidance

3. Distressing intrusive memories

4. Nightmares and distressing dreams

5. Problems with concentration

6. Exaggerated startle response

7. Low mood, if not depressed

8. Self-blame and intropunitive tendencies

Provide a DSM-5 Dimensional Diagnosis for This Case.

Provide a Brief Treatment Plan for This Case.

1. Describe each of the clients for whom the reports are written. How do these two clients differ?

2. What are the purposes for each of the reports?

3. What information does each report present?

4. How does the information in each report relate to the report’s purpose?

5. As a case manager, how might the contents of each report influence your work?

6. What questions do you have about the reports?

Discuss your responses to these questions with your classmates.

There are several strategies that can make history taking, social or otherwise, a positive experience for both the client and the case manager. First, remember that the main concern is the client, not the completion of a form or a survey. So, it is important to make sure that the client understands the reasons and benefits of the data gathering. Second, use this time to continue to build the relationship with the client. Being sensitive to the client’s wishes for privacy or need to discuss some aspect of his or her history will move the relationship forward. Finally, remember that it is important for the case manager to guide the interview, so maintaining a balance between relationship building and completing the interview are critical.

Using these strategies, the case manager gathers pertinent information about what appears to be the client’s problem. The primary source of information is the client, who is encouraged to tell the story in his or her own way. The helper listens carefully to what is said, how it is said, and what is not said. The sequence of events, reactions, feelings, and thoughts are all taken into consideration as the client relates the history. Note taking should be kept to a minimum so that important nonverbal information is not missed.

Social history is taken within the context of the culture of the client. For example, interviews with individuals who belong to a collectivist culture must be treated with cultural sensitivity. In a collectivist culture, the focus is on the importance of the group rather than the individual. In a collectivist context, individuals must fit into the group. There is a focus on group values, beliefs, and needs, and the group influences individual behavior.

Because of group influences, social history may hold very different meaning to an individual from a collectivist culture than it would to a person in the American mainstream. As the client responds to questions and tells his or her story, there may be much more emphasis on the family and the community. The client may not be able to clearly define personal characteristics or personal problems, but instead will describe them in terms of the group or family. It may appear that the client is avoiding answering the questions or not taking responsibility for his or her own behavior, but the client’s experience or history may be that of the group or the family. It is also possible that the client may not wish to share his or her story. In many collectivist cultures, this information stays in the family or in the group.

· Identifying information: Name, address, date and place of birth, social security number, military service, parents’ name and address, children’s names and ages.

· Presenting problem: Brief description of the problem.

· Referral: Source and reason.

· Medical history: Relevant hospitalizations, illnesses, treatment, and effects. Written permission is needed to obtain copies of medical records, if necessary.

· Personal/family history: Family life, discipline, parenting, and personal development.

· Education: Highest grade completed, progress, records.

· Work history: Training, type and length of employment, ambitions.

· Present family relationships and economic situation: Family members, ages, relationships, lifestyle, and income.

· Personality and habits: Interests, disposition, social activities, personal appearance.

· She did not come for her first appointment.

· The client drummed his fingers on the table throughout the interview.

· He states that his goal is to receive a high school diploma and get a job.

· The client stated that during the past week she and her husband had three fights.

The next examples are statements of information from other sources.

· Educational records indicate that the client completed the sixth grade.

· Her parents report that the client lived with them until her marriage 2 years ago.

· He was fired from his job for absenteeism.

· A psychological evaluation indicates a mildly retarded 13-year-old with possible hearing loss.

9-1kOther Types of Information

Other types of information may be relevant to the case file, depending on the agency’s mission and services as well as the client’s problem. Educational and vocational information, the most commonly needed, are discussed here.

Educational information can have many parts: test scores, classroom behavior, relations with peers and authority figures, grades, suspensions, attendance records, and indications of academic progress such as repeated grades or advanced work. The sources of educational information are just as varied: school records, teachers, guidance counselors, and principals. Often the particular information that the case manager obtains depends on which source is contacted. Rarely, is it gathered in a single report, as medical information might be. In many cases, the case manager decides what information is needed and contacts the source or sources most likely to have that information. For example, a teacher is probably the best source of information about classroom behavior, whereas school records provide test scores and indications of past academic performance. The contact may occur formally (in writing) or orally (by telephone or personal interview).

Deepening Your Knowledge: Case Study

Discussion Questions

1. In addition to the reports mentioned in this case, what other reports might Tom require to understand Sharon’s circumstances and needs?

2. What steps should Tom take to help Sharon prepare for and understand these assessments?

Author’s Note: We think that it is important for you to review the chapter you just read. We suggest the following.

· First, re-read the class discussion questions in the text and answer these as comprehensively as possible.