Needs Assessment and Treatment Plan

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CHAPTER SIX Service-Delivery Planning

·  We will work with our clients to develop a plan. This involves identifying goals, particularly little goals that are attainable in a reasonable amount of time. Sometimes it’s difficult for them to identify manageable goals, so we write a goal and then list some of the steps. We also identify the contribution of family, staff members, and friends.

·  —Intensive case manager, Los Angeles

At this point in the helping process, the agency has determined that the applicant meets the eligibility criteria and the services are appropriate, and the person can now receive services. The change in status from applicant to recipient of services marks the move into the second phase of the helping process: planning service delivery. In the opening example, case managers work with the client to develop a plan that is achievable.

This chapter explores the planning phase of the helping process, wherein the helper and the client together determine the steps necessary to reach the desired goal. The activities involved in this phase include the review and continuing assessment of the problem, the development of a plan, the use of an information system, and the gathering of additional information. Running through our discussion in this chapter are two critical components of the process—client participation and documentation. Review Figure 6.1  to see where service delivery comes into the helping process.

For each section of the chapter, you should be able to accomplish the  objectives  as follows:

Revisiting the Assessment Phase

· ■ List the two areas of concern that are addressed when reviewing the problem.

Developing a Plan for Services

· ■ Identify the parts of a plan.

· ■ Write a plan.

Identifying Services

· ■ Locate available services.

· ■ Create an information and referral system.

Gathering Additional Information

· ■ Compare interviewing and testing as data-collection methods.

· ■ Identify the types of interviews.

· ■ Show how sources of error can influence an interview.

· ■ Illustrate the role of testing.

· ■ Define test.

· ■ Categorize a test.

· ■ Identify sources of information about tests and the information that each provides.

Figure 6.1 The Helping Process

Revisiting the Assessment Phase

The next phase of the helping process begins with a review of the problems identified during the assessment phase. Before moving ahead with the process, the helper will need to know if the problem has changed, if the same client resources are available, and if any shift in agency priorities has occurred. In order to complete the review quickly before moving into a planning mode, the helper and the client examine two aspects of a case.

The first aspect of concern involves a review of the relevant facts regarding the problem. First, the helper and the client revisit the identification of the problem and whether it still exists. Working with people requires an element of flexibility; clients’ lives change, just as ours do. Thus, the problem may have changed in some way, the client may have a different perspective on it, the participants may be different, or assistance may no longer be needed, or appropriate, or wanted. Once the helper has confirmed that the problem still exists and has documented any changes that have occurred, the problem itself is revisited. Is the problem an unmet need, such as housing or financial assistance, or is it stress that limits the client’s coping abilities or causes interpersonal difficulties? Is the problem a combination of several factors? This activity is best accomplished by talking with the client and reviewing his or her file. The client is still considered the primary source of information and a partner in the helping process.

A second aspect of concern in the review of the problem requires an examination of available information to answer the following five questions:

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What is known about the source of the problem?

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What attempts have been made previously (before agency contact) to resolve the problem?

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What are the motivations for the client to solve the problem?

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What are the interests and strengths of the client that will support the helping process?

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What barriers may affect the client’s attempts to resolve the problem?

An important source of information is the client him- or herself. Talking with the client can reveal what he or she has thought about doing, what has been tried, and some possible solutions. Exploring with the client motivations, strengths, and interests reinforces the client’s experience that the helping process is a partnership between the client and the helper.

Other techniques that are helpful in reviewing the problem are observations and documentation. In the course of receiving the application, conducting the intake interview, making a home visit, or all three, the helper has had opportunities to observe the client. These observations may be richer if they occur in the home or in the office or if the client is accompanied by family members or a significant other. Information available from such observations includes the client’s thoughts, feelings, behaviors, and relationships.

Documentation in the case file also provides facts and insights about the client. Case notes, reports from other professionals, and intake forms help pin down past occurrences and pertinent facts about the present situation. Helpers who have a long history in service delivery may call on knowledge and experience from the past to understand a current case. Sometimes, knowledge comes from a helper’s own perception, instinct, kind of experience, street know-how. Many helpers mention rapid insights they sometimes have about a client, the client’s environment, possible difficulties, and creative approaches to the helping process. These insights are treated as just pieces of information and must undergo the same scrutiny as the other information collected.

Once the helper has revisited the problem, confirmed its existence, documented any changes, and reaffirmed the client’s desire for assistance, the two of them move to the next step of the planning phase, which addresses the need to determine the steps necessary to reach the identified goal or goals. This is the plan that will guide service provision.

Developing a Plan for Services

The  plan  is a document, written in advance of service delivery, that sets forth the goals and objectives of service delivery and directs the activities necessary to reach them. The plan also serves as a justification for services by showing that they meet the identified needs and will lead to desired outcomes. More specifically, a plan describes the services to be provided, who will be responsible for their provision, and when service delivery will occur. If there are financial considerations, the plan may also identify who will be responsible for payment. Sometimes financial support is available from outside sources, including the client and the family. Usually, the completed plan is signed by the client and the helper as the representative of the agency. It may then be approved by someone else in the agency before the authorization to provide services is granted.

Clearly, the plan is a critical document, since it identifies needed services and guides their provision. How is it developed? What is included? What are the goals and objectives? What factors might present planning challenges? These questions are answered as you read this section.

Plan development  is a process that includes setting goals, deciding on objectives, and determining specific interventions. The process begins with the synthesis of all the available data. This information is scrutinized carefully for as complete a picture of the case as possible. It is analyzed so as to identify inconsistencies, desirable outcomes, or both. It is also important to consider the veracity of the available data. For example, if substance abuse is a problem, how accurate is the client’s report of the amount of alcohol consumed daily or the extent of withdrawal (sleeping disturbances, d.t.’s, blackouts, convulsions, hallucinations, etc.).

In Roy Johnson’s case in  Chapter One , the information available at the time of plan development was derived from Roy’s application for services, the intake interview, reports from his orthopedic surgeon, case documentation, a general medical examination report, a psychological evaluation, and a vocational evaluation report. When Roy and his helper developed the plan of services, they reviewed and considered all this information using these steps:

· ■ Reread the client file and fill in the following categories on the worksheet: sources of information, relevant facts.

· ■ With this snapshot of the contents of the client’s file, assess and record conclusions, contradictions, and missing information.

· ■ Review this assessment with the client and make revisions according to his or her input and other new data gathered; fill in client motivations, strengths, and interests with client input.

· ■ Discuss with the client desirable outcomes.

Roy had a back injury and needed assistance finding a job; he also met economic eligibility criteria. His service plan, reproduced in  Figure 6.2 , included a program objective and intermediate objectives. For each objective, a service was identified, as well as a method of checking progress toward the achievement of the objective. The form also provided space to describe any other client, family, or agency responsibilities or conditions. Because this agency values client participation, Roy’s view of the program was also noted. Then both Roy and the helper signed the plan.

Figure 6.2 Roy Johnson Service Plan

Exactly what a plan looks like varies from agency to agency. However, if you are employed by an agency that provides human services, you can be sure that a plan will guide your work. Let’s examine the components of a plan of services.

Service plans are goal-directed and time-limited, so they should include both long-term and short-term goals. Long-term goals state the client’s specific desires for the ultimate changes in the situation. Short-term goals aim to help the client through a crisis or some other present need. Whatever the time constraints, goals establish the direction for the plan and provide structure for evaluating it.

Goals  are statements that describe a desired state or condition or an intent. For clients, a goal is a brief statement of intent concerning where they want to be at the end of the process; for example, “Learn daily living skills in order to live independently,” “Acquire knowledge and skills for a career in business communications,” or “Develop a support network for help coping with phobias.” Having written goals helps us focus on what we are trying to accomplish before we take action or provide any services. Action is often easy, but sometimes relating actions to outcomes is not. For accountability reasons, service provision is tied to outcomes. This makes writing goals a critical step in plan development. Remember that these broad statements of intent can be achieved only to the degree that their meaning is understood, so well-stated, reasonable goals are essential to problem resolution.

How does one write goals that are well stated and reasonable? Three criteria help us achieve this. First, the goal should be expressed in language that is clear and concise; second, the goal statement should be unambiguous; and third, the goal must be realistic and achievable. These criteria are illustrated in the following goals, which were established for a 74-year-old woman who will attend the Daily Living Program at the Oakes Senior Citizens Center.

Draft 1 is a goal statement for Ms. Merriweather; Draft 2 improves the statement by making it more clear and concise.

·  Draft 1: Ms. Merriweather will participate often in many of the Oakes programs that relate to sports, games, music, communication, exploring other cultures, and other educational programs as they are developed by the creative staff in the activities area. Draft 2: Ms. Merriweather will increase her social opportunities by participating in center activities.

A description of the plan is presented in Draft 1, below. In Draft 2, it is restated less ambiguously by defining who will help with medications and what the help entails.

·  Draft 1: They will work with Ms. Merriweather and her numerous family members to help with medications.

·  Draft 2: Nursing staff will develop a plan to administer Ms. Merriweather’s medication.

The goal in Draft 1, below, is to establish general physical goals for Ms. Merriweather.

Draft 2 restates these goals in realistic and achievable terms.

·  Draft 1: Ms. Merriweather will increase her range of motion, physical strength, and stamina.

·  Draft 2: Ms. Merriweather will participate four times a day in an exercise program that includes walking, weightlifting, and stretching.

Thus, goals are an important part of the service plan. They increase the chance of solving the problem by providing direction and focusing attention on well-expressed, reasonable statements. Because formulating goals also requires collaboration between the client and the helper, writing them also highlights their shared responsibility. Once a broad statement of intent has been agreed on, it is time to identify the activities that will lead to the desired outcomes. This process continues as a cooperative effort between the client and the helper. Activities are identified as objectives.

An objective is an intended result of service provision rather than the service itself. It tells us about the nuts and bolts of the plan—what the person will be able to do, under what conditions the action will occur, and the criteria for acceptable performance—so that we can know whether the objective has been accomplished. Objectives are useful for several reasons. First, they tell us where we are going. Second, they give the client guidance in organizing his or her efforts by stating the intervention or action steps. Third, they state the criteria for acceptable performance or outcome measures, thereby making evaluation possible. Objectives are all-important for the helper since they provide the standards by which progress is monitored. As progress is made, the helper adjusts the plan as needed.

Writing clearly defined objectives benefits the client, the helper, and the agency. Boserup and Gouge ( 1977 , p. 111) provide the following guidelines for writing and evaluating service objectives:

· 1. The statement of objective should begin with the word to followed by an action verb. The achievement of an objective must come as a result of action of some sort. Therefore, the commitment to action is basic to the formulation of an objective.

· 2. The objective should specify a single key result to be accomplished. For an objective to be effectively measured, there must be a clear picture of when it has or has not been achieved.

· 3. The objective should specify a target date for its accomplishment. It is fairly obvious that to be measurable, an objective must include a specific completion date, either stated or implied. If the objective is of a continuing nature, the target date could be assumed to be the end of the eligibility period. A situation of this nature may occur when services are being provided to a client whose prospects for improvement seem slim.

· 4. An objective should specify the what and when; it should avoid venturing into why and how. Once again, an objective is a statement of results to be achieved. The “why bridge” should have been crossed before the actual writing of the objective has started. The means of achieving an objective should not be included in the objective statement.

· 5. Objectives should be realistic and attainable but still represent a significant challenge. Because an objective can and should serve as a strong motivational tool for the individual worker and client, it must be one that is within reach. This simply means that resources must be available to achieve the objective.

· 6. Objectives should be recorded in writing. Each of us, whether consciously or unconsciously, has a convenient memory: We tend to remember the things that turn out the way we want them to and either forget or modify those things that are less than we wish. If objectives were not put in writing, it would be relatively easy to look on accomplishments as if they were in fact planned objectives. On the other side of the coin, one of the sharpest areas of conflict among helper, client, and supervisor is illustrated by such phrases as “I thought you were working on something else!” or “That’s not what we agreed to do” or “You didn’t tell me that’s what you expected.” Having objectives in writing will not eliminate all these problems, but it will provide something more tangible for comparison. Furthermore, written objectives serve as a constant reminder and an effective tracking device by which the helper, the client, and the supervisor can measure progress.

· 7. A statement of objective must be consistent with the available or anticipated resources.

· 8. Ideally, an objective should avoid or minimize dual accountability for achievement when joint effort is required.

· 9. Objectives must be consistent with basic agency policies and practices.

· 10. The client must willingly agree to the objectives without undue pressure or coercion.

· 11. The setting of an objective must be communicated not only in writing but also in face-to-face discussions with the client and the resource persons or agencies contributing to its attainment.

The following case example illustrates the development of goals and objectives (including intervention and outcome measures) with a client who is elderly and needs assistance.

The service coordinator identified two main goals for Mrs. Davis: to find affordable housing and to secure transportation that is appropriate. These are set forth in the Client Plan ( Figure 6.3 ).

The first objective toward the housing goal was to complete an application for a rent-controlled apartment with the city housing authority. Due to long waiting lists, this needed to be done within the week. The next step was to determine where Mrs. Davis preferred to live (probably close to the nursing home). After the application was completed, the service coordinator arranged for a volunteer to take Mrs. Davis to look at several apartments and to meet with apartment managers to find out about waiting lists (Mrs. Davis couldn’t afford to wait for long). The service coordinator found a volunteer to help with this. Once Mrs. Davis decided on an apartment, other volunteers assisted with the move. Her son could afford to rent a moving truck and to drive the truck, although he couldn’t lift or carry due to medical problems. The time allotted for these objectives was workable, and the objectives were met within a month.

The objectives for the goal of transportation were to apply for the Trans-lift along with CAC vans. Obtaining an assessment from the Office on Aging was also an objective; that agency provided escorted transportation for medical appointments and necessary errands for people over 60. This service would be available until Mrs. Davis was accepted by another agency that provides transportation.

In this case, the plan identified services and then guided the delivery of those services. The goals and objectives in the plan were developed using the guidelines suggested previously. Note that each objective clearly defined the intervention or action steps, stated who would provide the service, and stated a time frame for service delivery. The outcome measures were clear and the plan was implemented successfully.

Often, planning is not quite so easy. Suppose Mrs. Davis refuses to rest as prescribed or is insistent that she will continue to ride the bus. Or perhaps there are no transportation services in her community or agency rules limit services to those who have no other family. As you can see, a number of challenges may appear during plan development. Sources of these challenges include but are certainly not limited to clients themselves, family members, funding restrictions, agency policies and procedures, eligibility requirements, or lack of community resources. Barriers can also be more intangible: client values, the denial of problems, cultural prohibitions, reluctance, or lack of motivation. All of these possibilities present opportunities for the helper’s resourcefulness and creativity; for example, working with a client to develop a plan that is congruent with client values and desires, understanding cultural norms, mobilizing resources, consulting with colleagues, and networking with other agencies. Many of these challenges must be resolved in order to move forward with identifying services.

Figure 6.3 Client Plan for Mrs. Davis

Identifying Services

Once the plan is complete and has been agreed on by the client and the helper, it is time to begin thinking about the delivery of services. A well-developed plan provides information about what the service is, who will provide it, what the time frame is, and who has overall responsibility for service delivery. It is the helper’s responsibility to implement the plan. What are these responsibilities? How does one begin implementation? These questions are explored next.

Identifying services has been compared to the brokering role. In both situations, the helper is involved in the legwork and planning that is necessary for implementation. As a broker, the helper facilitates client access to existing services and helps other service providers relate better to clients. This linking of clients and services also occurs as the helper arranges for service delivery. The steps are similar.

Information and Referral Systems

One of the most helpful tools for a helping professional is knowledge of the human service delivery system in the community. Who do you know? What services are available? How does one access the services? Is there a waiting list? One of the challenges facing new helping professionals is to establish an information and referral system . For helpers with experience, the challenge consists of continually developing and updating their systems. Knowing what an information and referral system is, how to set one up, and how to use it are valuable skills in helping.

There are three components to information and referral. One component is the  social service directory , which usually lists the kinds of problems handled and the services delivered by other agencies. In some communities, these are published by a social service agency, by a funding source such as the United Way, or (as a community service) by a business or organization. Sometimes these directories are available on the Internet. Another component is the  feedback log , which provides feedback to the agencies that deliver services to help ensure quality information and referral services. Some agencies accomplish this through forms that record referrals, give information on the services needed, and provide the referral agency with information on the services received. If the client takes the form to the agency providing services, it may also serve to remind the client of the appointment. A third component of information and referral systems is staff training. In these sessions, the helper may be introduced to the services of the employing agency as well as those of other agencies. Other information and referral data that are shared during staff training may include reviewing and updating referral procedures, announcing new services or ones that no longer exist, and discussing the effectiveness and efficiency of service delivery.

Social service directories may have two indices: one that is an alphabetical listing of agencies and one that is a categorical listing of services. Each entry in the directory lists the agency’s name, address, phone number, and services. Also listed may be fees, hours of service, eligibility criteria, and sources of agency support. Here is an example of an entry.

Existing directories are important resources for the helper, but sometimes establishing one’s own system is useful for filling in the gaps in published directories or for recording detailed information that may be of special interest to the individual helper.

Setting Up a System

The first step in establishing one’s own information and referral system is to identify all agencies and available services. This includes listing agencies previously contacted, checking the Yellow Pages of the telephone book, browsing the Internet, and talking with other professionals. Each agency and service becomes part of a card file, a computer file, a spreadsheet, or an online directory that is easy to update. The file can also be expanded by talking with clients (particularly those who have been in the human service system for some time), meeting other professionals at meetings and workshops, and attending community meetings.

Whether using cards or electronic files, this information is easy to use when identifying the client problem and matching it with a service. However, since a client rarely has only one problem, using the file may not be so simple. First, the client and the helper prioritize the problems. Once this has been done, the helper identifies which problems the agency will address and which ones need referral. These additional services can be found by checking the file. If there is more than one resource to serve the client’s particular need, the helper works to identify the agency that can meet the client’s needs in a manner responsive to the client’s values and concerns.

·  Deborah Caudill is an 18-year-old client who needs long-term counseling to work on the anger she feels toward her father for deserting the family when she was 11. Lou Levine, her social worker, knows that the counseling Deborah needs is beyond the scope of the services provided by the agency where she works. Two other agencies in their community offer long-term counseling for adolescents. Because Deborah and Lou agree that counseling would be beneficial, they discuss these two agencies. Deborah has questions about their locations, who provides the counseling, whether it is group or individual, and how much it will cost. Lou consults her file for the answers to these questions and provides Deborah with the information, and then they discuss the pros and cons of each option. The social worker’s file indicates that one center provides counseling services and is well known for its work with adolescents. In addition, the latest entry in the file indicates that Jane Barkley, a previous client, had a positive experience there.

Establishing and using an information and referral system requires certain skills of the helper. Being able to identify the client’s problem, the community resources available to solve it, and the viable alternatives are all critical to the success of the system. Choosing a resource or a service requires the client’s participation. The client may actually have the final say in the selection of the agency or service; the more accurate and complete the information about the agency, the better the decision will be. Finally, good research skills are helpful to locate potential community resource alternatives and to update data on existing agencies and services.

Part of the development of a plan is identifying services to meet the client’s needs. The development of an information and referral system is useful here. Throughout plan development, data gathering continues to take place.

Gathering Additional Information

Gathering additional information may be part of the planning process or part of the plan itself. To decide whether additional information is necessary, there must be a review of available information from other agencies, the referral source, employers, and others. The key to determining what is needed is relevance. Is the needed information relevant to the client and to service provision? Will it contribute to a complete array of social, medical, psychological, vocational, and educational information about the client? Once it is determined that additional information is necessary, the helper decides how the information will be obtained. In some cases, the helper can personally acquire the information, but it may also be necessary to consult family members, a significant other, or professionals such as psychologists, physicians, and social workers. The client also continues to be a primary source of information and is part of the decision-making process regarding the additional information needed and who can provide it. Next we introduce two data-collection methods that helpers use;  Chapter Seven  explores what data are available from other professionals.

Two primary tools are available to the helper for data collection: interviewing and testing. They are similar in several ways. The information is used to describe the situation, to make predictions, or both. Each may occur in an individual or group situation in which some type of interaction occurs. The group situation may be an interview with a family or a test administered to more than one examinee. Both interviews and testing have a definite purpose, and the helper assumes responsibility for conducting the interview or administering the test.

Interviewing

There are different types of interviews (Kaplan & Saccuzzo,  2009 ). The  assessment interview  is an interaction that provides information for the evaluation of an individual. The interview may be structured or unstructured; it uses both open-ended and closed questions. The intake interview is an example of an assessment interview in which the applicant provides information that helps in evaluating him or her and the problem in relation to the mission, resources, and eligibility criteria of the agency.

A  structured clinical interview  consists of specific questions, asked in a designated order. This type of interview is structured by guidelines to ensure that all clients are handled in the same way. The structure also makes it possible to score the responses. One advantage of this type of interview is its reliability, or consistency; flexibility is limited. Although it is a valuable source of information, the interview results should be interpreted with caution. The major limitation is its reliance on the respondent as an honest and capable interviewee who has skills for self-observation and insight.

A more comprehensive interview is the  case history interview . This interaction includes both open-ended questions and specific questions. Topics may include a chronology of major events, the family history, work history, and medical history. Usually an interview of this type begins with an open-ended question or statement: “What was school like for you?” “Tell me about your work history.” “What do you remember as the happiest times when you were growing up?” “Describe your relationship with your parents.” These probes may be followed by specific questions, which may or may not be dictated by agency forms or guidelines. “When did you quit your last job?” “What grade did you complete in school?” “Are you the oldest child?” are questions that contribute to understanding the client’s background and uncovering any pertinent information.

Technology is also an influence on interviewing. Many times, an interview takes place via computer rather than face-to-face. Questions are presented and followed by a choice of responses:

Are you married?   Yes   No

If the answer is yes, then another question related to marriage may follow.

Is this your first marriage?   Yes   No

If the answer to the first question is no, then another question appears.

Did you complete high school?   Yes   No

The computerized interview is a good way to collect facts about a person. The limitations are that there is no nonverbal communication and the feelings of the client are not shared. Important information may be lost as a result of these limitations.

The mental status examination described in a previous chapter is a special type of interview used to diagnose psychosis, brain damage, and other major mental health problems. Its purpose is to evaluate a person thought to have difficulties related to these problems. This type of interview requires the helper to have some expertise on major mental disorders and the various forms of brain damage.

The skillful interviewer also needs to know about  sources of error  in the interview. Awareness of sources of potential bias in the instrument itself or in the interviewer enables the helper to compensate for any resulting distortions. A look at interview validity and reliability will help us identify potential sources of error.

For a number of reasons it is often difficult to make accurate, logical observations and judgments. One reason is the  halo effect  (Whiston,  2009 ), which can occur in an interview situation when the interviewer forms a favorable or unfavorable early impression of the other person, which then biases the remainder of the judgment process. For example, an unfavorable initial impression can make it difficult to see positive aspects of a client or a case. If a home visit to an apartment in a housing project reveals an unkempt, dirty, and very sparsely furnished living area, the interviewer may find the visit unpleasant. The resulting interview with a single-parent resident is likely to be rushed and cursory, with little chance of gaining insight into any problems. The helper may also find it difficult to maintain eye contact with the parent, thereby missing important nonverbal cues. Other contacts with this parent may be influenced by the memory of the physical setting.

A second cause of invalidity in an interview is “general standoutishness” (Hollingsworth,  1922 ). This is the tendency to judge on the basis of one outstanding characteristic, such as personal appearance. An attractive, well-groomed individual might be rated more intelligent than a less attractive, unkempt individual. Consider a helper who makes a home visit to investigate a child abuse report. The address is in an affluent suburb and the house is a stately two-story brick house with elaborate landscaping. The initial impression of neatness, money, and social standing may influence the investigator’s interaction with the parents and the subsequent course of the investigation.

Cultural differences can also contribute to error. To take an extreme example, a helper has been asked to visit a family that recently emigrated from India and has just moved into a rent-controlled apartment in the city. It is her last stop of the day, and she finds that she has interrupted a puja (prayers of thanks for their new home). She finds family members seated on the floor around a small fire in a pot. Appalled that they have started a fire in the house she puts it out immediately and begins lecturing the family on fire safety. When she finally begins to talk about the services that are available, the family does not respond.

As you can see, sources of error can prejudice interview validity. Error reduces the objectivity of the interviewer, often leading to inaccurate judgments. The more structured the interview is, the less error there will be. Because an interview does provide important information, the helper can consider the information tentative and seek confirmation from other sources, such as more standardized procedures. Similarly, test results are more meaningful if placed in the context of a case or social history or other interview data. The two can complement each other.

The reliability of an interview is its consistency of results. In interviewing, this means that there is agreement between two or more interviewers in their conduct of the interview, the questions they ask, and the responses they make. As you might imagine, reliability varies widely. The reliability of structured interviews is higher because they have more stringent guidelines concerning the questions and even the order of the questions. (The downside is that this structure limits what is obtained.) In general, interview data have limited reliability, because interviewers look for different things, have various interviewing styles, and ask different questions. It is important for the helper to verify information with other sources over time.

Testing

In the previous section, testing was recommended as one way to verify the information gathered in an interview. Most people encounter tests shortly after beginning school. How we perform on tests affects our lives, and test scores have become key factors in many decisions. They influence placement in special academic classes; the assignment of labels such as “high achiever,” “mentally challenged,” and “compulsive”; admission to schools and colleges; and job selection. In fact, test scores are more important today than ever before.

Helping professionals encounter tests in various contexts; for example, test reports from other professionals. In some cases, the information consists of test scores and nothing more.  Figure 6.4  shows one example of how test results may be communicated.

Figure 6.4 Test Data

Figure 6.5 Test Administered and Results

In other cases, test scores are part of a written report that also gives some explanation of the scores. Figure 6.5  is an excerpt from a report on a 37-year-old white male who was hospitalized for depression. He has completed two years of college and has been a personnel interviewer for ten years. To use this information, the reader of the report must have knowledge of tests and an understanding of test data. A helper may also encounter testing as a service offered by an agency. For example, a statewide evaluation facility located on the campus of a school offers services that include achievement testing for placement at the school and vocational testing for career development. Workers at the evaluation facility administer these tests to each client who is referred to the facility. Scores are interpreted and included in their evaluation reports, which are sent to the referring helper. There may be other situations in which knowledge of testing is important. For example, a case worker may be asked to select tests to be administered as part of the services required in a plan. This task requires knowing the sources of information about tests, the criteria for selecting a test, and eligibility for purchase and use. Such knowledge is also important when the case worker encounters a situation like the following:

·  A family in my caseload had trouble understanding the results of a recent assessment test that was administered at their son’s elementary school. The school psychologist who originally explained the results of the test used terms unfamiliar to the parents and did not answer the questions they asked. And the parents felt that if they understood the results of the test, they could help their son in the areas where he was weakest. The parents have asked me to look at the test results and explain them again.

The helper needs an appropriate level of testing knowledge in order to use tests as a resource. Because tests have assumed such importance today, particularly in decision making, helpers must think carefully about the role of testing in their work with clients. To make proper use of test results, one must understand the test being used; the purpose of the test and its development; its reliability and validity and its administration and scoring procedures; the characteristics of the norm groups; and the test’s limitations and strengths. Many helping professionals include a course in testing as part of their academic preparation.

WHAT IS A TEST?

A  test  is a measurement device. A  psychological test  is a device for measuring characteristics that pertain to behavior. It is a way to evaluate individual differences by measuring present and past behavior. For example, the test your instructor will give you to measure your mastery of this material will provide an indication of what you know now. Tests also attempt to predict future behavior. You may have taken the Scholastic Assessment Test (SAT) or the ACT as part of the admission requirements to college. One or the other is usually required by higher education institutions as a predictor of success in college.

One important caution needs to be noted here: a test measures only a sample of behavior. Tests are not perfect measures of behavior; they only provide an indication. It is therefore important that case managers not make decisions based solely on test scores.

TYPES OF TESTS

Thousands of tests are in use today. One way to make sense out of all the tests that are available is to know how they are categorized. One classification is by type of behavior measured. Two categories are identified in this system: maximum performance tests measure ability and typical performance tests give an idea of what an examinee is like. A discussion of these and other helpful categories follows.

Maximum performance tests  include achievement tests, aptitude tests, and intelligence tests. On these tests, examinees are asked to do their best.  Achievement tests  are used to evaluate an individual’s present level of functioning or what has previously been learned. Achievement tests that a case manager will often encounter include the Test of Adult Basic Education (TABE) and the Wide Range Achievement Test (WRAT).  Aptitude tests  provide an indication of an individual’s potential for learning or acquiring a skill. Because aptitude tests imply prediction, they are useful in selecting people for jobs, scholarships, and admission to schools and colleges. The SAT is an aptitude test. In your work with clients, you will likely read about aptitude tests such as the General Aptitude Test Battery (GATB), the Differential Aptitude Test (DAT), and the Minnesota Clerical Test.

When we think about how smart someone is, usually we mean intelligence. Tests such as the Wechsler Adult Intelligence Scale (WAIS), the Wechsler Intelligence Scale for Children (WISC), the Revised Beta Examination (Beta IQ), and the Peabody Picture Vocabulary Test are  intelligence tests . Careful consideration should be given to these tests and test scores because intelligence can be defined in a number of ways. Some tests measure verbal intelligence, some measure nonverbal intelligence, and others measure problem-solving ability. The WAIS, for example, yields a Verbal IQ, a Performance IQ, and a Full-Scale IQ. On the other hand, the Revised Beta Examination yields only a performance IQ score called a Beta IQ.

The other major category is the  typical performance test . Such tests provide some idea of what the examinee is like—his or her typical behavior. In this category are interest inventories (California Picture Interest Inventory, Strong Interest Inventory Test, Kuder Preference Record), personality inventories (Edwards Personal Preference Schedule, Minnesota Multiphasic Personality Inventory, Sixteen Personality Factor Questionnaire), and projective techniques (Rorschach Inkblot Test, Thematic Apperception Test, Rotter Incomplete Sentences Blank). Other well-known performance tests are the Bender-Gestalt Test, the Vineland Social Maturity Scale, and the McDonald Vocational Capacity Scale.

There are a number of other categorization schemes for tests. Individual tests, such as the WAIS or the projective techniques, are administered to one person at a time. Group tests are administered to two or more examinees at a time. The Revised Beta Examination and the Otis Lennon School Ability Test are group tests, although they can also be administered on an individual basis. Tests can also be classified as standardized or informal. Standardized tests are those that have content, administration and scoring procedures, and norms all set before administration. Informal tests are developed for local use; for example, the test your instructor will give to you to measure your mastery of this course material. Verbal tests use words, whereas nonverbal tests consist of pictures and require no reading skills. Tests in which working quickly plays a part in determining the score are speed tests. Tests such as the Revised Beta Examination are closely timed. In contrast, power tests have no time limit, or one that is so generous that it plays no part in the score.

As you begin to explore the testing literature, you will discover that testing has a language of its own. Recognizing the categories and knowing their meanings will help you develop the vocabulary to understand testing concepts and the advantages and limitations of tests. Selecting tests requires an understanding of the terms in the following list, as well as others.

·  Edition: the number of times a test has been published or revised

·  Forms: equivalent versions of a test

·  Level: the group for which the test is intended (e.g., K–3 is kindergarten through third grade)

·  Norm: the average score for some particular group

·  Norms table: a table with raw scores, corresponding derived scores, and a description of the group on which these scores are based

·  Percentile rank: the proportion of scores that fall below a particular score

·  Reliability: the extent to which test scores or measures are consistent or dependable—that is, free of measurement errors

·  Test: a measurement device

·  Test administrator: person giving a test

·  Test profile: a graph that shows test results

·  Validity: the extent to which a test measures what it claims to measure

SELECTING TESTS

When faced with the task of choosing a test to administer, the first question must be where to find out about available tests. The second question, which quickly follows once a helper realizes the vast number of tests that are available, is how to select a test.

There are many sources of information about tests, ranging from test publishers to reference books available in the library to an Internet search. These sources provide more detailed information about a test. The general information about a test can help you narrow the choices to those of interest, and it is for these tests that more specific information is gathered. Let’s begin with the more general information.

Thousands of commercially available tests in English are described and critically reviewed in the many editions of the Mental Measurements Yearbook, or MMY, published by the Buros Institute of Mental Measurements at the University of Nebraska–Lincoln. Begun in 1938 by Oscar K. Buros, the MMY provides comprehensive reviews of tests by almost 500 notable psychologists and education specialists (Kaplan & Saccuzzo,  2009 ). For each test included in the MMY, there is a detailed description and price, followed by references to articles and books about the test, along with original reviews prepared by experts. The MMYcontains no actual tests.

Another reference that summarizes information on tests is Tests in Print. This volume is helpful as an index to tests, test reviews, and the literature on specific tests. Entries include the title and acronym of the test, who it was designed for, when it was developed, its subtests, the authors and publishers of the test, and cross-references to MMY. Other references may be helpful to you as you narrow your selection, butMMY and Tests in Print provide the most comprehensive overviews of published tests now available.

Once the choice has narrowed, specimen sets of tests are available for purchase from test publishers. Although there are approximately 400 companies in the test industry, the top 10 percent are responsible for 90 percent of the tests used in the United States. Test publishers have catalogs that provide lists of tests and test-related items sold by that company. Companies usually offer specimen sets for sale: the test manual, a copy of the test, answer sheets, profiles, and any other appropriate material related to a particular test. The test manual—the best source of information about a particular test—provides statements about the purposes of the test, a description of the test and its development, standardization procedures, directions for administration and scoring, reliability and validity information, norms, profiles, and a bibliography. This specific information clarifies the decision to use a particular test.

Once available information about a particular test is gathered, the helping professional decides whether to select it. Then the second question, relating to the criteria for selection, surfaces. One helpful source of information is Standards for Educational and Psychological Testing, published by the American Psychological Association. The Standards is a technical guide that provides the criteria for the evaluation of tests. Among the standards discussed are validity, reliability, test administration, and standards for test use. Any helping professional who is involved in testing should carefully review the complete standards.

Helping professionals may be asked to interpret test results. Two essential steps in test interpretation are understanding the results and communicating them to another person, orally or in writing. The following suggestions will guide your preparation for test interpretation.

· ■ Know the test—its purpose, development, content, administration and scoring procedures, validity and reliability, advantages and limitations.

· ■ Avoid technical discussions of tests. Use short, clear explanations of what you are trying to communicate.

· ■ Use the test profile as a graphic presentation of the test results. The examinee may find this easier to follow as the scores are explained.

· ■ Explain what the score means in terms of behavior.

· ■ Go slowly. Give the examinee time to process the information and react.

Tests are helpful tools in measuring traits common to many people. A score serves to show where a person stands in a distribution of scores of peers. How high or low a score is does not measure an individual’s worth or value to family, friends, or society. A guiding principle for professionals who use tests is to consider scores as clues. They do mean something, but in order to know what, we must consider each examinee as an individual, combining test evidence with everything else we know about the person. It is unsound practice for helping professionals to base important decisions on test scores alone. It is important to remember this in test selection, administration, and interpretation.

SUMMARY OF TESTING

Test misuse can easily occur. Let’s review some guidelines for the selection, administration, and interpretation of tests.

First, helpers should select tests that they have carefully reviewed. The validity, reliability, and usability of a test; its statement of purpose, content, norm groups, administration, and scoring procedures; and its interpretation guidelines should all be evaluated in light of the intended use. The helper should check any reviews by experts to add to his or her knowledge of the test. One way to get to know a test is to take the test yourself.

Second, helpers should use only tests they are qualified to administer and interpret. This often depends on one’s ability to read the manual. Other tests require advanced coursework and supervision or practicum experiences for proper administration and interpretation. Test catalogs usually indicate how much expertise is required for the tests listed. Another helpful source of information is the Standards for Education and Psychological Testing.

Third, helpers who administer tests or request tests have an obligation to provide an interpretation of the test results. An understanding of raw scores and their conversion to standard scores, coupled with the ability to communicate the meaning of the scores, is necessary to do this right. In addition, it is essential to be aware of the norm groups and their applicability to the examinee. Some groups, such as Latinos, African Americans, and rural populations, may be underrepresented in the establishment of norms.

CHAPTER SUMMARY

This chapter has introduced the planning phase of the helping process, which includes a number of stages and strategies. Planning begins with a review and continuing assessment of the client’s problem and strengths. Two areas of concern during this time are a consideration of the problem and the available information about the problem obtained from various sources, including previous attempts to resolve it and potential barriers to problem solving.

The development of a plan guides service provision. Planning is a process of setting goals and objectives and determining intervention. A goal is a brief statement of intent concerning where the client wants to be at the end of the process. Objectives provide the standards by which progress is monitored, the name of the person who is responsible for what actions and when they will be carried out, and the criteria for acceptable performance. Identifying services is a critical part of a well-developed plan. Linking clients and services is facilitated by information and referral systems, which include social service directories, feedback logs, staff training, and updated directories.

Some professionals prefer setting up their own information and referral systems. Part of the planning process or the development of the service plan may be gathering additional information. Two data-collection methods used by helping professionals are interviewing and testing. Assessment interviews, structured clinical interviews, case history interviews, and mental status examinations are the four types of interviews commonly used in this process. Potential sources of error include the halo effect and general standoutishness. Testing, a second data-collection method, is encountered by the helper in reports, in case files, and as a service offered by an agency. Understanding test language, concepts, sources of test information, and the factors included in selecting, administering, and interpreting tests facilitates the meaningful use of test scores.

CHAPTER REVIEW

In this review you have an opportunity to review important planning concepts. Writing a service plan, identifying services, and gathering additional information are all skills that follow the review. Reviewing key terms and answering the discussion questions will help you affirm the knowledge you have gained in this chapter.

KEY TERMS

Achievement test

Aptitude test

Assessment interview

Case history interview

Feedback logs

Goals

Halo effect

Information and referral system

Intelligence test

Maximum performance test

Objectives

Plan

Plan development

Psychological test

Social service directory

Sources of error

Structured clinical interview

Test

Typical performance test

REVIEWING THE CHAPTER

1.

Describe the two areas of concern addressed by revisiting the assessment phase.

2.

What sources facilitate the review of a client problem?

3.

What role does documentation play in the review of the problem?

4.

Define plan.

5.

What activities occur before development of the plan?

6.

List the characteristics of a service plan.

7.

What are the benefits of establishing goals?

8.

List the criteria for well-stated and reasonable goals.

9.

Distinguish between a goal and an objective.

10.

Identify a problem you would like to address, and develop a plan with goals and objectives.

11.

What are some of the challenges of plan development?

12.

List the three components of information and referral and give an example of each.

13.

Discuss the similarities between interviewing and testing.

14.

Compare the four types of interviews and their roles in the helping process.

15.

Illustrate how sources of error may affect an interview.

16.

How do helping professionals use tests?

17.

Describe the different ways to categorize a test.

18.

Identify the two essential steps in test interpretation.

QUESTIONS FOR DISCUSSION

1.

Why do you think developing a plan is important?

2.

If you were a new helper, how would you begin to develop a network of available services?

3.

What kinds of criteria would you use to determine if a structured interview is appropriate with an 8-year-old?

4.

Do you believe that you will be able to determine what errors exist in the information that you gather? What problems do you expect to encounter in finding errors?

REFERENCES

Boserup, D. G., & Gouge, G. (1977). The case management model. Athens, GA: Regional Institute of Social Welfare.

Hollingsworth, H. L. (1922). Judging human character. New York: Appleton-Century-Crofts.

Kaplan, R. M., & Saccuzzo, D. P. (2009). Psychological testing: Principles, applications, issues. Pacific Grove, CA: Brooks/Cole.

McClam, T. (1992, September–October). Employer feedback: Input for curriculum development.Assessment Update, 4 (5), 9–10.

Whiston, S. (2009). Principles and applications of assessment in counseling (2nd ed.). Belmont, CA: Thomson Brooks/Cole.

CHAPTER SEVEN Planning Skills

Service delivery is at the heart of the helping process. Planning occurs before effective and efficient delivery of services and with a review of the assessment phase. This chapter will help you master the skills that are necessary to move through the helping process. Writing a plan, identifying services, and gathering additional information are some of the basic planning skills that you will practice.

Exercise 1: Back to the Future

Planning generally implies future direction; however, in the helping process it begins with an assessment that looks backward rather than forward. The following situation illustrates this reassessment activity:

·  Frankie and John sought help originally because they desperately needed financial assistance. John, a police officer, was diagnosed with brain cancer about the same time Frankie had their second child, another boy. Shortly after, Frankie’s dad died, leaving them his home that he had refinanced to help Frankie and John with their medical expenses. They are now living in the house, although they feared they may lose it because John’s disability is not enough for them to pay the mortgage. Last Friday evening, Frankie discovered they had a winning lottery ticket. Now they have $1.5 million.

Does the problem continue to exist?   YES   NO

Has it changed in any way?

 

 

Who is involved at the present time?

Describe any shifts in the environment.

What changes do you anticipate in plan development?

Exercise 2: Planning in Your Life

Think for a moment about a trip you’ve taken recently. You knew your destination but there were also a number of other considerations: Was it a trip you had taken before? Did you know the way or was it a new experience? Did you choose the scenic route or the interstate? Who went with you? When did you plan to arrive at your destination? How many stops did you make? In reality, you plan every day—for example, how you will tackle a class assignment, what you will do over the coming weekend, and how you will accomplish everything you’ve set out to do today. All require planning. Or you may have a larger project ahead of you: losing weight, planning a wedding, finding a job, or moving to another residence. Your assignment here is to select a task or project and develop a plan to guide your actions.

Project: ___________________________________________________________________________

Goal 1: ____________________________________________________________________________

Objective 1: ________________________________________________________________________

Objective 2: ________________________________________________________________________

Goal 2: ____________________________________________________________________________

Objective 1: ________________________________________________________________________

Objective 2: ________________________________________________________________________

Exercise 3: Plan Review

Review the goals and objectives you established in the previous exercise. Evaluate your goals and objectives by responding to the following items:

Goals
Are they broad statements of intent?	YES	NO
Do they specify where I want to be at the end?	YES	NO
Are they reasonable?	YES	NO
Do they reflect my values and preferences?	YES	NO
Are they clear and concise?	YES	NO
Are they achievable?	YES	NO
Objectives
Does each objective begin with to followed by an action verb?	YES	NO
Do my objectives state an intended result?	YES	NO
Does each objective specify who, what, and when?	YES	NO
Do I venture into why and how?	YES	NO
Is each objective measurable?	YES	NO
Is it attainable?	YES	NO

Exercise 4: Working through the Planning Process

1.

Read the following case of Renda, a welfare mother.

I was a client in the human service system for a long time. The beginning of my life as a client actually happened when I was still with my husband. He was not supplying any money to our family. We could not afford diapers, food, or anything for our home. We lived out in the middle of nowhere in a broken-down trailer with no electricity, hot water, things like that. I had to go to Social Services to try to get some food for my child because she literally had no food or diapers. I found out that my husband, now my ex-husband, was using the welfare money to gamble. I finally left my husband due to abuse. I was tired of being beaten up and tired of being emotionally abused by him. At that point, I was totally dependent on the welfare system. I received state funds to take care of my daughter, medical insurance, and other things. I didn’t know where else I could go. I had very few options. I could either go to work at minimum wage or apply for welfare. Applying for welfare would allow me to go back to school, at least for a little while. The social service agencies helped me apply for grants and loans so I could go back to school.

The very first time I went to a meeting at social services was to gain help not only for my daughter and me but also for my husband. When I went back the second time to apply for assistance just for my daughter and me, I ended up getting a really wonderful worker, Cindy. When I went in to see her, she could . . . I don’t know, we just clicked and it was almost like she said, “You need to cry.” And I said, “Yeah.” At that point I was living in a women’s abuse center. I had no self-esteem, no self-respect. I was in the gutter, literally. I did not know where to go. After my talk with Cindy, she summarized my needs: money, school, insurance, and child care. Of course, she said, that was only her first shot at identifying my problems.

2.

Review Renda’s statement about her first and second visit with her case worker and revisit the assessment phase by answering the following questions:

· ■How did Renda’s problem change?

· ■What do you know about the sources of the problems?

· ■What are Renda’s interests and strengths that support the helping process?

· ■What barriers may affect Renda’s attempts to resolve the problems?

3.

Before developing a plan for services, the helper integrates all information about the client. The planning form that follows Renda’s description of her life is one structured way to assemble this information.

· Things were really difficult for me before I left my husband. He broke into my home and further destroyed the trust that I had in people. Here I am, not only abused but I have my home broken into and my daughter is almost kidnapped. So it was really hard. I was as low as any person can get on the earth. Lucky for me, a great family stood behind me. The women at the shelter backed me in everything and sometimes would fight with me to get me to express my feelings. That was one thing that I did not do very well to begin with. I did not openly express how I was feeling or how things were going until the point they would literally have to pull it out of me.

· The shelter is a remodeled old house, and it is beautiful. There was almost a family atmosphere there. When I was at the shelter, three other ladies and their children were there. I had the youngest child. We shared the household chores, like the cooking and the cleaning. We even shared watching each other’s children. For example, if I had a court date, I didn’t have to worry about child care. I didn’t want to drag my one-year-old child to the courthouse. We would do the same when one of the other ladies had to go to court. My daughter and I had one bedroom to ourselves and there was a TV room and a playroom for the kids. And there were four workers. There was one worker who focused on the children who were not able to go to school because they were hiding.

· Before I went to the shelter to escape from my husband, I lived in a trailer where I was not able to see anybody because I was scared he would find us. I could not go any place. I was stuck in that trailer, 24 hours a day, 7 days a week. I was never out of that home except for the front porch. So it was very hard for me to get out and see people again.

· My daughter also suffered through all of this. She sensed my fear. My husband wanted to kill me and kidnap her. I had a gun. I had double locks on the trailer. I could not let my daughter go outside and play by herself. She was a prisoner in her own home. But I refused to let him have her because I did not want her to grow up in a drug and alcohol environment.

· My husband has been in the penitentiary for a while, so she has not seen him. His mother, her grandmother, did take her to the prison once. Now I will not let her see her grandmother either.

· My daughter cannot sleep and she has terrible nightmares. She cries for seemingly no reason at all. She did not deserve what she had to go through. I know that she has psychological problems; she will not listen to me. She is very disobedient and sometimes she is violent. I know that her daddy abused her, too. I never saw him do it, but I do know that she had marks on her body. Sometimes I just had to leave her alone with him. We don’t really have any concrete evidence, and my daughter will not talk about her father at all.

· I told you that I cannot let her out to play by herself. She hates that. Whenever she does go somewhere, she seems to get lost. She just wanders off and does not see any problem with it. In fact, she really does not like anyone telling her what to do. I have had to take her to the emergency room four times this last year because she just pushed physical limits. One day she decided that she would live beneath the sofa. She wasn’t really small enough to do this, and she eventually got stuck. I had to cut the bottom of the sofa to get her out, but I didn’t get her out safely. The emergency room doctor said that he had heard all kinds of stories, but none like this. She had to have seven stitches in her arm where she cut herself when she tried to wiggle out.

4.

Now that you have more information about Renda and her situation, complete the Client Worksheet.

CLIENT WORKSHEET Client: ___________________________ Date: ____________________________

SOURCE OF INFORMATION

RELEVANT FACTS

CONTRADICTIONS

CLIENT MOTIVATIONS

CLIENT STRENGTHS

CLIENT INTERESTS

5.

Assume you are Renda’s human service worker. List three goals and two objectives for each goal.

· Goal 1: _________________________________________________________________

· Objective 1: _________________________________________________________________

· Objective 2: _________________________________________________________________

· Goal 2: _____________________________________________________________________

· Objective 1: _________________________________________________________________

· Objective 2: _________________________________________________________________

· Goal 3: _____________________________________________________________________

· Objective 1: _____________________________________________________________

· Objective 2: _________________________________________________________________

6.

Evaluate the goals and objectives you have written using the following standards:

Goals
Are they broad statements of intent?	YES	NO
Do they specify where I want to be at the end?	YES	NO
Are they reasonable?	YES	NO
Do they reflect my values and preferences?	YES	NO
Are they clear and concise?	YES	NO
Are they achievable?	YES	NO
Objectives
Does each objective begin with to followed by an action verb?	YES	NO
Do my objectives state an intended result?	YES	NO
Does each objective specify who, what, and when?	YES	NO
Do I venture into why and how?	YES	NO
Is each objective measurable?	YES	NO
Is it attainable?	YES	NO

7.

Read about the experience Renda and her daughter have with the helping process.

· Cindy was my case worker for two years. She was the best support for me. Many workers have such large caseloads; they explain the services that you are to receive and then say, “I’ll see you again in six months.” Cindy was not like that. In fact, she helped me find more services for my daughter and me. She knew a lot of professionals, and they really helped me get what I needed.

· During this time I also had some testing. Cindy helped me through this. I had to take a drug and alcohol assessment to determine if I had substance abuse issues. The judge ordered the tests to help decide custody of my daughter. When the welfare office found out about it, they wanted the results. It was really weird. During the testing, they made sure I didn’t have any urine on me. They also asked me thousands of questions. And one of the questions that was hardest for me to answer was, “How old were you when you took you first drink”? If I had told them how old I was when I had my first alcoholic drink, they would have said, “Red light! She is an alcoholic.” And so I explained, “I am not from the United States. I grew up in Germany. The cultures are different. So when I tell you don’t be shocked.” They continued to run medical tests. They did blood tests and more urine tests. They had to have four samples, so they would call me up at 7:30 A.M. and ask me to be here at 8:15. I would have to get up and run to the testing office. It was literally random.

· I also had to take tests before I could go to college with agency support. They gave me vocabulary tests and a skills test just to see how well I would do if I went back to college. The highest that you could test was 12th grade, 8th month. That is what I tested. I had this test after I had my first interview with Cindy. I think it was like a basic GED test, but I am not positive. I had social studies, English, math, science, a lot of reading. I was put in this room and I had these little bubbles to fill in. They graded it then and there.

· Cindy tried to point me in different directions. Each direction meant more interviews, more tests, and more assignments. But I had confidence that she was working for me. She was there with the compassion and caring. At the beginning of service delivery, she put me in touch with agencies that would help supplement my income so I could afford diapers, formula, and other things for my daughter. There were several churches in the county that helped me. One of them was Cindy’s church. At one point I was going through a very bad depressive state and the doctor wanted me to take some antidepressants. Medicaid did not cover those. Her church paid, once they had information from the doctor that these were medications that I needed.

· Later, Cindy helped when my daughter was having trouble. She sent us to a local mental health center, and they did an assessment. They looked at her environment, her physical condition, and her psychological condition. She also was assessed at a genetic center. I had to go through another interviewer, who took the family tree and the entire family background of both my side of the family as well as my ex-husband’s. I had limited knowledge of his family background. Then we went to a screening. They did eye tests on her. They did motor skills tests. They would ask her questions in a certain order. And I also had to answer a questionnaire about her behavior. It came to the point where she was at home hurting herself. She was literally injuring herself. After this screening, they made specific recommendations about where she should go to preschool and the kind of environment she should have. They also diagnosed her with Oppositional Defiant and Attention Deficit Disorder.

8.

Prior to service delivery, the helper may need additional information about the client. Interviews and tests are two ways of gathering this additional information. Renda describes some of her experiences with interviews and tests.

· ■If you were the helper how would you use this information?

· ■List the interviews and tests that Renda describes and summarize their purposes.

· ■Add the information gained from these tests to fill in the Client Worksheet that follows. How does this information change your goals and objectives? Be specific.

CLIENT WORKSHEET Client: ___________________________ Date: ____________________________

SOURCE OF INFORMATION

RELEVANT FACTS

CONTRADICTIONS

CLIENT MOTIVATIONS

CLIENT STRENGTHS

CLIENT INTERESTS

Exercise 5: Test Resources

A new agency policy requires that all individuals accepted for services complete an interest inventory. Your supervisor has asked that you select three different inventories to present to the staff for their consideration.

1.

Review the information on testing in  Chapter Six .

2.

Identify sources of information about testing. List three.

3.

What information do you expect to get from each source?

Source 1: ______________________________________________________________________

Source 2: ______________________________________________________________________

Source 3: ______________________________________________________________________

Exercise 6: Test Analysis

Your agency has decided to use the Mooney Problem Checklist as an initial interviewing and counseling tool. You have been asked to present an analysis of this instrument in the next staff meeting. To do that, you must find the following information:

1.

Title and any abbreviations or acronyms

2.

Author and institution or affiliation

3.

Publisher

4.

Copyright date

5.

Purpose and recommended use

6.

Administration. Describe briefly. Include timing and instructions.

7.

Describe scoring procedures. How are scores expressed?

8.

How will you explain the scores to your client?

9.

List your sources of information.

10.

What other sources of information would be helpful?

In More Depth: It’s “Our” Plan

Planning comes naturally to many of us. For some, the process occurs in our heads. We never write a thing—it’s strictly a mental activity. Others depend on writing, usually in the form of lists. These identify the tasks to be accomplished, the items needed, or both. Helping agencies and organizations require formal plans, documents that capture the planning process in writing. In this age of accountability and client involvement, plans also require the client’s signature—evidence that the client is aware of the plan and is in agreement with the goals, objectives, and activities. A key to the success of plan development and the resulting signed document is a collaborative relationship with the client.

Successful helping requires client involvement throughout the process, but one of its most critical places is in plan development. This activity is similar to the trip planning activity in Exercise 2. On the trip to a written plan, you now have a passenger, and the efforts of both the driver and the passenger are necessary to arrive at the destination. If you and your client are going in different directions, then you both have a problem. An efficient trip will have a single destination, two drivers who share the duty, some stops along the way, and an agreement about the route. Upon reaching the destination, both travelers are satisfied. The same applies to plan development. The goal is a written document that pleases both the client and the helper. At different points in plan development, the helper and client may alternate taking the lead. Sometimes it’s not a smooth process; for example, there are bumps in the road, other passengers join them, roadblocks appear, or alternate routes are necessary. A collaborative effort enables arrival at a destination (or written document in helping language) that satisfies all involved. This section focuses on the skills that are necessary to make this collaboration succeed.

One approach to client involvement is the helper’s familiarity with the plan used by the employing agency or organization. Many agencies use a form that is completed by filling in the blanks. Other agencies require a plan that involves composing prose—a written proposal for services. Others may have a fairly elementary chart. Examples of different planning documents follow. As you examine these documents, identify the components common to all of them. Knowing what the plan requires for completion will help you use your skills to encourage client involvement in making decisions about the plan’s content.

Example 1

THE PLAN

CLIENT: _____________________________________________ Age: ________

PROBLEM: ________________________________________________________

Goal 1: ____________________________________________________________

Objective: __________________________________________________________

By (date): _____________ Responsible Person: ____________________________

Goal 2: ____________________________________________________________

Objective: __________________________________________________________

By (date): _____________ Responsible Person: _____________________________

Goal 3: ____________________________________________________________

Objective: _________________________________________________________

By (date): _____________ Responsible Person: ____________________________

Example 2

Excerpt from a high school Individualized Education Plan with transition goals for a student with a severe disability:

Example 3

As you examined these documents, you probably noted that common to all of them are three components: goals and objectives, activities to reach them, and in one of them, a place for the signatures of the client and the helper. The signatures at the end of the plan are an indication of the partnership that was integral to its development. What are the skills necessary to make this happen? How do the helper and the client become partners in plan development? The following activities provide a foundation for the partnership.

Information

Self-determination is an ethical principle that underlies work with clients. The client has the right to know what the planning process is and may have questions about it. What is the plan? What does it look like? Why is a signature necessary? Is it carved in stone? Do I have to do everything? Who else will know about it? What if I fail? How do we fill it in? Demystifying the planning process is an important beginning. It is much easier to participate in an activity if you know what it is and what the expectations are for your participation.

Before explaining the process, the helper carefully considers the level of explanation and uses words that the client will understand. Depending on how much information the client can grasp at one time, the helper also asks for questions (“Do you have any questions about the form?”), provides clarification (“Goal is a complicated term. Maybe it would help if I gave you some examples.”), focuses on strengths (“I remember when you told me about building a birdhouse and being able to follow the plan. This is a similar process, only you and I will come up with the plan!”), and requests feedback (“Tell me what you think about all this.”). Finally, the helper listens carefully to the client’s comments and suggestions. This particular moment in plan development can be a significant and positive step for the client. Focusing on a new beginning, grasping the steps in the process, and having a say in his or her own service plan are empowering. This is consistent with the ethical obligation we have to our clients to respect their right to self-determination mentioned earlier.

Part of sharing information involves “nuts and bolts.” Often, helpers skip this part, assuming that the client knows or that the client will “catch on.” Many times clients don’t know who will do what when, how they will know when they reach the end, what their role is, what the helper does, and how long the whole process will take. Role induction, a term Meier and Davis (2005) use, describes the client’s introduction to the process and what the expectations are for his or her involvement. Understanding these facets adds structure to the process and clearly spells out the client’s role and the helper’s role. It would be a mistake to skip this step if client participation is important.

Client Input

It is within the helper’s power to make the client a partner in the process. The case of Frankie and John illustrates the importance of reassessment. Before the case manager and the client can move forward, they must step back. Has the client changed? Does the problem still exist? Any shifts in the environment? In Frankie and John’s situation, drastic changes required a change in the service plan. So this “look back” is important. A primary source of information in this activity is the client. This marks the beginning of client involvement in planning.

Client input is also important throughout the rest of planning. A number of examples illustrate this involvement. As the client and the helper move forward to establish goals and objectives, the client’s values and preferences are considered. The evaluation of the goals as realistic and attainable and the sequencing of steps is also a joint effort. The helper also continues to focus on client strengths. Finally, the client is charged with the responsibility for providing updates on progress, changes, or problems.

None of this may come naturally to a client. In fact, it may represent an entirely new way of thinking and call for new skills. In the past, clients may have been limited to convergent thinking—that is, believing that there is only one answer or solution to a problem. Probes and reinforcing statements are ways to encourage a divergent approach—if several right answers or solutions are possible. Examples of probes and reinforcing statements follow.

Probes that seek more information from the client

· ■ What would your life be like if …

· ■ List some changes that make sense to you.

· ■ What would you be doing differently with other people?

· ■ How would your behavior be different from the way it is now?

Reinforcing statements to support and encourage the client’s participation

· ■ That’s an interesting idea.

· ■ These ideas are really creative.

· ■ Good thinking! Any more ideas?

Relationship Development

Planning offers many opportunities to build and strengthen the relationship between the helper and the client. Numerous skills contribute to communicating to the client that the helper understands the client’s thoughts and feelings (Brammer & MacDonald,  2003 ). These include listening (eye contact, nodding, verbal following), clarifying (“Let’s talk about what’s going on with you”), perception checking (“You seemed confused about these two goals. Is that right?”), and paraphrasing (a brief restatement of the client’s words). Of these, listening is the key. In fact, effectiveness as a helper is tied to the helper’s ability to communicate to the client that the helper understands the client’s thoughts, feelings, and behaviors. From this understanding comes confidence in the helper’s ability to help.

Other helping skills that facilitate relationship development are reflecting, supporting, and summarizing. Read the following dialogue to see how these responses facilitate both understanding and the relationship.

·  CLIENT: I was so angry after I talked with the woman who answered the phone. She was no help at all, and I didn’t know where else to turn. And she didn’t help with that either. I was abandoned.

·  HELPER: At a time when you really needed some direction, you didn’t get it, and you are still furious about your conversation with her. (Reflecting)

·  CLIENT: Exactly. I don’t think she should be doing that job if she’s not going to be helpful to people who call. I was desperate. I didn’t know where to turn. We had nothing—no food, no home, no transportation, no money. It is devastating to lose everything. A fire destroys everything. Our lives are gone.

·  HELPER: As awful as this has been for you and your family, and it has been a terrible experience, you have a safe place to stay for a month or so. That was very resourceful of you. And now you have time to think about what you want to do. (Supporting)

·  CLIENT: Yes, we have some time to think about the future—a place to live, going back to work, school. In a way, starting over is okay. It’s just so hard to lose things you can’t replace. Those are the real losses.

·  HELPER: Yes, they are, and you must be sad when you think about the pictures and other family mementos that are gone. It’s another loss to cope with. We’ve talked about a number of these losses today. Let’s take a minute and look back at what we’ve discussed. You’ve been through a terrible time, and we’ve talked about the losses you’ve experienced as well as the frustrations that you’ve experienced in getting help. How does it look to you at this point? (Summarizing)

During plan development there will be times when the client will ask for information: “Where should I go to see about this?” or “What happens during a psychological evaluation?” or “Who can tell me about that?” Many times it is appropriate to respond to the client’s request for information. Other times the client asks for advice (“What should I do about this?” “What do you think I should say to her?” “Tell me how to respond to that.”), and here the helper should exercise caution. Limitations to advice are the clients usually don’t follow it or, if they follow it, they may find it is invalid and end up blaming the helper for things not turning out right. A more effective approach to informing is being tentative (“One approach might be …”), being sure of your knowledge or expertise, and knowing the sources of your information (Brammer & MacDonald,  2003 ). Nothing will destroy the relationship faster than invalid advice, bad information, or coercion.

Although the helper has used the planning process and is an expert in reassessing, writing a service plan, and gathering additional information, it is important to pace the work to fit the client’s needs and skills. The client may need additional time reassessing his or her situation or may not be clear about priorities or goals. Respecting the client’s needs for more time conveys that the process is for the client and that the planning is a collaboration.

Success

The final product of plan development is the written plan. This document will demonstrate the client’s involvement in the process and the partnership between the client and the helper. It will take the form of the assignment or designation of roles and responsibilities, reflect the values and preferences of the client, and adhere to the rules and regulation of the agency.

Finally, the signature of the client and the helper will be the final evidence that it is “our plan.”

CASE STUDY

Gloria came to the United States from Puerto Rico to study sign language and interpreting. There are very few people in Puerto Rico with these skills. Her husband is disabled, his disability check is not enough to support a family of five, and she wants training so that she can help support her family.

From her pastor in Puerto Rico, she learns about a training program at a university in the southeastern United States. The program pays each participant a stipend for living expenses as well as tuition and fees. Gloria moves to the United States and begins the program. Her husband and three children eventually join her, and they move to a two-bedroom apartment in the university housing complex. In addition to the problem of crowded living conditions, neither the husband nor the children speak English. Her husband never leaves the apartment. They are settled one month when the problems begin.

Exercise 7: Meet Gloria

Your assignment is to meet Gloria and learn about her problems. First, view the introductory comments from Gloria on the website that accompanies this book,  www.cengagebrain.com/shop/ISBN/1111298432 , and respond to the following questions:

1.

What are your initial impressions of Gloria?

2.

Describe all of the times you have difficulty understanding her.

3.

What do you know about Puerto Rico and its culture?

Exercise 8: Problem Statements

Gloria briefly describes each problem she encountered after one month with her family in the United States. Write problem statements based on what she says.

· Problem One

Problem Statement:

· Problem Two

Problem Statement:

· Problem Three

Problem Statement:

· Problem Four

Problem Statement:

· Problem Five

Problem Statement:

· Problem Six

Problem Statement:

Exercise 9: Developing a Plan of Services

You now have a sense of the experiences Gloria has had and some of the challenges she faces. Develop a plan of services to assist Gloria. Rather than providing services for each problem, review your problem statements and initial goals. Think about ways to combine the needs she has to most efficiently and effectively plan.

Exercise 10: Anticipated Challenges

You have listened to Gloria, identified her problems, and developed a service plan for her. Answer the following questions.

1.

Identify the challenges you think you might face in working with Gloria, who may have a different cultural background from you. Specifically, how are the following illustrated with this client?

· Accent:

· Language:

· Cultural norms:

· Gender issues:

· Collectivist culture:

2.

As you work with Gloria, how will you encourage her participation in plan development?

3.

Describe her values and preferences based on her discussion of the six problems listed in Item 1 of this Exercise.

4.

What skills would you use to encourage her to share values, preferences, and other information about herself and her situation? Provide examples.

5.

How can the plan reflect her values and preferences? Are there goals and objectives that you would change now that you better understand her values and preferences?

6.

Do you think she will sign the plan you developed? Why or why not?

SELF-ASSESSMENT

1.

Describe three important concepts related to service-delivery planning.

2.

Explain how these concepts support your service-planning work with Gloria.

3.

Review the planning forms presented in this chapter. Which form seems most useful for you to use in planning? Why?

REFERENCES

Brammer, L. & MacDonald, G. (2003). The helping relationship: Process and skills (8th ed.). Needham Heights, MA: Allyn and Bacon.

Meier, S. T., & Davis, S. (2008). The elements of counseling. Pacific Grove, CA: Brooks/Cole.

CHAPTER EIGHT Building a Case File

·  You’re only going to get so much information from just looking at the file. You’re going to know much more when you actually sit down to talk with clients to see what their situation is. And then you will be able to determine what other information would be helpful and from whom.

·  —Social service interviewer, Dearborn, MI

Information from other professionals comes to the helper in two ways. When he or she receives a case file on a client from another agency or worker, it may contain reports or evaluations from other professionals. In other situations, the plan developed by the helper and the client may include referrals to other professionals for evaluations. In both situations, the helper must be able to understand the information provided and (if asking for help from other professionals) to know just what to request. In the example above, the interviewer talks about information available in a client’s file and the need to seek additional information. The client is a good source of the information, as are other agencies and professionals. The case file is continuingly being built.

This chapter examines the types of information that may be found in a case file or that must be gathered to complete one. Exactly what information is needed depends on the individual’s case and the agency’s goals, but many cases involve medical, psychological, social, educational, and vocational information. We introduce each type of information, give a rationale for gathering it, describe the kinds of data likely to be provided, and discuss what the helping professional needs to know in order to make the best use of the report. Review  Figure 8.1  to see the place that building a case file has in the helping process.

For each section of the chapter, you should be able to accomplish the following objectives.

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.

· ■ Describe the type of information provided by the DSM-IV-TR.

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.

Figure 8.1 The Helping Process

Medical Evaluation

Knowledge of medical terminology, conditions, treatments, and limitations is important in understanding a case. Medical information may be provided on a form or in a written report. The exam and report may have been prepared by a general practitioner or by a specialist in a field such as neurology, orthopedics, or ophthalmology. In some cases, the helper can interact with the medical service provider and thus be able to ask questions, request specific assistance, or offer observations. Often, however, he or she does not have this opportunity and must rely on the written report. There are several resources that may prove particularly helpful. Many agencies have a copy of the Physician’s Desk Reference (PDR) or other medical guide. Some also have a physician serving as a consultant, who is available to answer questions. This section introduces basic medical information to help you understand medical terminology.

Agencies approach medical information in different ways. Some require documentation of a mental or physical disability or condition in 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, “the description in a medical report addresses 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” (Dabatos, Rondinelli, & Cook,  2000 , p. 81).

Each medical evaluation includes recommendations that take into account the individual’s physical, emotional, and intellectual capacities. Following 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, limited lifting, and limited need for close work.

Often, however, the form for a general medical examination allows only a small space for the diagnosis, so the helper 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.

Medical Exams

Generally, medical information contributes to a case in two ways.  Medical diagnosis  appraises the general health status of the individual and establishes whether a physical or mental impairment is present. For example, 10-year-old Bobby Jones comes into state custody, abandoned by his parents. The helper in the assessment, care, and coordination team takes Bobby to the health department for an examination. The examination results in a diagnosis of otitis media.

Diagnostic medical services include general medical examinations, psychiatric evaluations, dental examinations, examinations by medical specialists, and laboratory tests. A medical diagnosis is helpful when the client has a medical problem or is currently receiving treatment from a physician, who may provide important information about social and psychological aspects of the case in addition to the medical aspects. When making a referral for a medical diagnosis, the helper should help the client understand why the referral is necessary, the amount of time it will require, what the client can expect to learn, and what use the agency will make of the report.

Medical consultation  is used in several ways. First, the consulting physician can provide an interpretation of medical terms and information. For example, Bobby Jones was diagnosed with otitis media. The helper received this report, asked a colleague what the diagnosis meant, and learned that it was an ear infection. A consultation with a physician would reveal that otitis media is a severe ear infection that sometimes results when the eustachian tubes are not properly angled. The consultation might also explain the report further and clarify possible treatments. In Bobby’s case, the helping professional may need further information about the advantages and disadvantages of two possible treatments: insertion of tubes in the ears and a regimen of antibiotics. A consultation with an otorhinolaryngologist (ear, nose, and throat specialist) could shed light on the medical prognosis and the extent of any hearing disability that might be expected.

The role of a medical consultant is to interpret the available medical data, determine any implications for health and employment, and recommend further medical care if needed. The helper can make the best use of a consultant by being prepared for the meeting, perhaps specifying in writing what is needed from the consultant. This usually involves identifying problems that need to be resolved and setting forth the significant facts of the case. The helper needs to understand medical terminology, the skills of specialists in diagnostic study and treatment programs, and the effects of disability on a client.

The medical service used most often in human services is the  physical examination , in which a physician obtains information concerning a client’s medical history and states the findings. The exam data are entered into the medical record. Here we give an overview of the physical examination: the kinds of information obtained and what the helper needs to know to make such a referral and to understand the physician’s report.

Diagnosis  involves obtaining a complete medical history and conducting a comprehensive physical exam (also called a physical, a health exam, or a medical exam). The results of the exam may be reported on a form provided by the referral source. Sometimes physicians use preprinted schematic drawings of various body parts or organ systems to enhance or clarify the written report. However the information is transmitted, the quality of the reporting depends on the relationship between the physician and the client. In some cases, the client has mixed feelings about the referral for a physical exam. He or she needs an explanation of why the referral is necessary, the amount of time the exam will take, what outcome is expected, and how the information will be used. Keep in mind that the client’s socioeconomic status, language-skill limitations, or cultural background may also influence how he or she feels about the referral. If it is communicated with sensitivity, and if a good relationship with the physician is established, any barriers of anxiety, depression, fear, or guilt can be overcome.

The general medical exam is done by a physician, who takes an overall look at the person’s medical state. Its purpose is to evaluate the person’s current state of health, focusing on two areas. First, a complete medical history records all the factual material, including what the client states and the physician’s inferences from what is not said. A typical starting point is the chief complaint, as expressed by the individual. If there is an illness at present, it is described in terms of onset and symptoms (including location, duration, and intensity). A family history relates significant medical events in the lives of relatives, particularly parents, grandparents, siblings, spouse, and children. Extensive information about the individual’s past medical history is also collected. This may include childhood diseases, serious adult illnesses, injuries, and surgeries. A review of symptoms focuses on information about present and past disorders, which the physician elicits through questions about organs and body systems. After completing the physical exam, the physician records a diagnostic impression. The actual diagnosis is made once there is conclusive evidence, which may mean getting further studies or referring the client to a specialist for consultation.

What exactly makes up a medical exam? Techniques used during a physical exam are inspection, palpation (feeling), percussion (sounding out), and auscultation (listening). Usually, the examining physician works from the skin inward to the body, through various orifices, and from the top of the head to the toes (Felton,  1992 ). Special instruments are used to look, feel, and listen. More time is spent in particular areas to ascertain whether a certain finding truly represents a change in an organ or tissue. Some parts of the exam are carried out quickly, and others require more time. More important areas may receive a second, more thorough examination. The physician records the findings as soon as possible after completing the exam and shares the results with the client.

For some clients, one of the first things that occurs in the helping process is a referral to a physician for a general medical exam. The physician conducts the exam and then he or she completes a form that is sent to the referring helper. It becomes part of the client record.

Medical Terminology

Medical reports often include  medical terminology , which may seem like a foreign language to a helper who is unfamiliar with it, because physicians rely on technical words and phrases for exactness. Medical specialties also have specific terminologies. Other professionals who may write reports using medical terminology are nurses, physical therapists, and occupational therapists. It can be a challenge for the helper to make sense of these reports; he or she must have at least a rudimentary understanding of medical terminology.

It is a continuing challenge for helping professionals to keep current with terminology because of ambiguities, inconsistencies, and the changing course of medical knowledge. Although most word roots have Greek or Latin origins, some occur in both but have different meanings. The root ped, for example, means “child” in Greek (e.g., pediatrician), but in Latin ped means “foot” (e.g., pedicure). Many diseases are named for individuals, such as Alzheimer’s disease and Hodgkin’s disease. Some disorders are called syndromes: Cushing’s syndrome, Horner’s syndrome. Acronyms or abbreviations are formed from the initials of lengthy terms: MRI (magnetic resonance imaging) and ACTH (adrenocorticotropic hormone) are examples. In addition, medical terminology traditionally uses hundreds of abbreviations; some of the most common are listed in  Table 8.1 . Keeping informed about trends in medicine increases one’s understanding of the meanings of terms. For example, physicians increasingly prescribe generic drugs rather than brand names (e.g., diazepam rather than Valium). Keeping current with medical terminology entails awareness of chemicals, syndromes, and diseases that are newly named and sometimes given acronyms or abbreviations (e.g., AIDS for acquired immunodeficiency syndrome). It must also be remembered that words can have multiple meanings and that several names may apply to a single entity.

TABLE 8.1 Medical Abbreviations

Abbreviation	Meaning	Abbreviation	Meaning
a.c.	before meals	L-1, L-2, L-3	lumbar vertebrae (by number)
b.i.d.	twice daily	LLQ	left lower quadrant
B.P.	blood pressure	LMP	last menstrual period
C-1, C-2, C-3	cervical vertebrae (by number)	p.c.	after meals
CBC	complete blood count	p.r.n.	as needed
CNS	central nervous system	q.i.d.	four times daily
DX	diagnosis	RLQ	right lower quadrant
F.H.	family history	RX	treatment
GI	gastrointestinal	S-1, S-2, S-3	sacral vertebrae (by number)
GU	genitourinary	T-1, T-2, T-3	thoracic vertebrae (by number)
HDL	high-density lipoprotein	t.i.d.	three times daily
h.s.	at bedtime	WBC	white blood count
H & P	history and physical examination

Psychological Evaluation

The objective of a psychological evaluation is to contribute to the understanding of the individual who is the subject. The report writer is a consultant who makes a psychological assessment that is practical, focused, and directed toward the solution of a problem. The psychological report he or she prepares is more than a presentation of data. This section helps you determine when a psychological evaluation is needed, how to make the referral, and how to prepare the client. The evaluation itself and the report are also discussed.

Referral

Helping professionals may refer clients for psychological evaluations for a number of reasons. One reason is to establish a diagnosis in order to meet criteria of eligibility for services.

·  Nadine is a deeply depressed 15-year-old who is currently taking antidepressant medication. She is increasingly out of control. Yesterday, she slapped her grandmother, with whom she lives, and threatened to kill her. If she is to receive services in an inpatient treatment program, she must have a diagnosis confirming emotional disturbance.

Another reason for a psychological evaluation is to provide justification for a particular service.

·  Amal is a 28-year-old male whose divorce will be final in a month. As the court date approaches, Amal feels more and more depressed. He is having trouble getting up in the morning, showing up for work on time, and maintaining relationships with those who are close to him. His physician has suggested counseling, but Amal’s insurance company insists that he have a psychological evaluation to determine whether or not he needs it.

Sometimes a psychological evaluation functions as a screening or routine evaluation to obtain information about a client’s personality, aptitude, interests, intelligence, and achievement.

·  Greg is a 35-year-old male who is the only child of elderly parents. He is cognitively impaired. His parents, concerned about who will care for Greg if something happens to them, have learned of a group home where the residents live under close supervision. One requirement for acceptance into the program is a recent psychological evaluation that assesses intelligence as well as ability to function independently.

A helper may also order a psychological evaluation to resolve contradictions or ambiguities or to add information that is missing.

·  Paloma is a 10-year-old who is enrolled in public school. Her teacher is concerned about her behavior. One day she is passive, rarely interacts with her classmates, and does not participate in class. The next day, she may be loud, talkative, and disruptive. Just yesterday, she started a fight with a classmate. This has prompted her teacher to request an evaluation from the school psychologist.

Finally, a psychological evaluation may be recommended to answer particular questions regarding the client. Is there brain damage? Why does the individual have trouble relating to others? How is this person adjusting to the recent amputation of her leg? Why is the client doing poorly in school?

In any of these situations, a referral for a psychological evaluation is appropriate. In each case, the professional seeks help in order to provide the client with needed services. It is easiest to get what is needed if the consulting psychologist knows the general mission of the agency and understands the specific problem to be addressed. Having this information allows him or her to choose the most relevant and efficient approach to gathering the needed information. The referral for a psychological evaluation is usually made by a helping professional, who specifies what is needed: a routine workup, testing, questions about the case, a diagnosis. Thus, the psychologist is charged with a mission. It is therefore critical that the referral be more than a general request, such as “psychological evaluation” or “for psychological testing.” These terms communicate poorly; the referring professional has failed to express what prompted the referral. Two scenarios may result: The psychologist may ask the helper for more specific information, or he or she may try to guess what is wanted or needed. When the reason for the referral is not clear, it is difficult for the psychologist to provide a useful report.

How does a helper make a good psychological referral? First, it is important to be clear about the reason for referral. The helping professional must clarify the need for documentation of a condition or disability, obtaining test scores, or the exploration of behavioral inconsistencies. Specific questions also help the psychologist focus on the client’s problems. The psychologist then makes recommendations to the helper. The two professionals can discuss the case before the evaluation to clear up any questions or needs. Since 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 helper 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 helper considers them crazy. Demystifying the evaluation helps to dispel these attitudes.

The 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.

One of the primary ways that a psychologist observes current behavior is by testing. From the discussion of testing in the previous chapter, you know that testing gives samples of behavior. That discussion also introduced a number of tests that are useful in human services. Psychologists use many of them, notably the WAIS and projective tests (such as the Rorschach and Thematic Apperception Test). These tests are individually administered and scored, and psychologists are specially trained to use them. As a consultant, then, the psychologist decides what kinds of data must be gathered to carry out the assignment given by the referral source, which findings have relevance, and how these findings can be most effectively presented.

The results of the psychological evaluation are communicated to the helper in a written report. The psychological report  is a written document that explains an individual’s personal characteristics, mental status, and social history. This document provides information that helps determine what are the problems and challenges facing the client and what might be possible interventions. The report may appear in one of several forms, the most common of which is a narrative (illustrated by the report included in this section).

Results may also be communicated as a terse listing of problems and proposed solutions. Another option is the computer-generated report, usually consisting of a sequence of statements or a profile of characteristics. Less frequently used are checklists of statements or adjectives, clinical notes, and oral reports relating impressions. Since the narrative is the form of psychological report that is most often used in human services, let’s explore it further.

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 classification system for diagnoses used in the United States is published by the American Psychological Association in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,Text Revision (American Psychiatric Association,  2000 ). Many helping professionals receive reports based upon a  DSM-IV-TR  diagnosis. Understanding what the various diagnoses and scores mean will support the helper’s understanding of the challenges the clients face. At times, professionals will submit a DSM-IV-TR diagnosis and a treatment plan. After consulting with the professional, the helper may provide supportive services. Let’s see what types of information a DSM-IV-TR diagnosis provides.

The DSM-IV-TR codes include a broad range of psychological disorder categories, such as adjustment disorders, substance abuse, attention-deficit/hyperactivity disorder, cocaine use, major depressive disorder, and schizophrenia. The DSM-IV-TR uses a multi-diagnostic approach that helps assess clients using multiple factors. There are five axes used in the diagnostic system.

Axis I focuses on disorders known as “clinical syndromes.” This means that there is a cluster or a group of symptoms that exist for several particular disorders. Clinical syndromes include the following:

· ■ Disorders usually first diagnosed in infancy, childhood, or adolescence

· ■ Organic Mental Disorders

· ■ Substance-Related Disorders

· ■ Schizophrenia and other Psychotic Disorders

· ■ Mood Disorders

· ■ Anxiety Disorders

· ■ Somatoform Disorders

· ■ Dissociative Disorders

· ■ Sexual and Gender-Identity Disorders

· ■ Eating Disorders

· ■ Sleep Disorders

Axis II provides a framework to help professionals identify individuals with personality disorders. An Axis II diagnosis indicates that an individual has a personality trait(s) for a long period of time. These traits restrict the individual’s positive interaction with others and limit the individual’s success in social and work situations. Axis II also includes Mental Retardation. Axis II diagnoses include:

· ■ Paranoid Personality Disorder

· ■ Schizoid Personality Disorder

· ■ Antisocial Personality Disorder

· ■ Borderline Personality Disorder

· ■ Histrionic Personality Disorder

· ■ Obsessive-Compulsive Personality Disorder

· ■ Mental Retardation

Axis III includes General Medical Conditions that may be related to the diagnoses in the other axes. At times the mental disorder is a direct result of the medical condition. Other times, the medical condition exacerbates the disorder. Sometimes one or more of the symptoms of the disorder are related to the medical condition. Diseases that are components of the General Medical Conditions are listed below.

· ■ Infectious and Parasitic Diseases

· ■ Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders

· ■ Diseases of the Blood and Blood-Forming Organs

· ■ Diseases of the Circulatory System

· ■ Diseases of the Respiratory System

· ■ Diseases of the Digestive System

TABLE 8.2 Excerpt from the DSM-IV-TR: Codes for Adjustment Disorders and Attention-Deficit/Hyperactivity Disorder

·  Adjustment Disorder ·  309.0 With Depressed Mood ·  309.24 With Anxiety ·  309.28 With Mixed Anxiety and Depressed Mood ·  309.3 With Disturbance of Emotions and Conduct ·  309.9 Unspecified ·  Attention-Deficit/Hyperactivity Disorder ·  314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type ·  314.00 Attention-Deficit/Hyperactivity Disorder, Predominately Inattentive Type ·  314.01 Attention-Deficit/Hyperactivity Disorder, Hyperactive-Impulsive Type

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 2000 American Psychiatric Association.

Axis IV provides an opportunity for the professional to list Psychosocial and Environmental Problems related to the diagnosis and the treatment. These factors include problems in living, family and other relationships, and social support. Also included are work related difficulties, financial problems, access to needed services, and legal difficulties.

Axis V is a Global Assessment of Functioning (GAF) Scale. At this time the professional assesses the individual’s overall ability to function in interpersonal, social, occupational, and family settings. Many professionals will provide this one score at the beginning of treatment, during treatment, at the end of treatment, and during follow-up to assess the client’s progress. The scale rates the individual from 100 to 1. A rating of 100-91 means that the individual is able to cope well in multiple circumstances. A rating of 50-41 indicates that the individual demonstrates an inability to function in arenas such as family and work. A rating of 10-1 means the individual is dangerous to self and other.

Reading diagnostic criteria from the DSM-IV-TR helps you understand how the professional makes the diagnosis. For example,  Table 8.2  presents a detailed list of adjustment disorders and attention-deficit/hyperactivity disorders taken from the DSM-IV-TR. This information illustrates the range of disorders that an individual may experience. The professional believes that the more accurate the diagnosis, the more closely the treatment can be matched to the individual’s experience.

As stated earlier, the DSM-IV-TR describes criteria for specific disorders. The following is an excerpt from the DSM-IV-TR that establishes the criteria for a diagnosis of autistic disorder (American Psychiatric Association,  2000 , pp.70–71). 299.00 Autistic Disorder

· A. A total of six (or more) items from 1, 2, and 3, with at least two from 1, and one each from 2 and 3:

· 1. qualitative impairment in social interaction, as manifested by at least two of the following:

· a. marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction

· b. failure to develop peer relationships appropriate to developmental level

· c. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)

· d. lack of social or emotional reciprocity

· 2. qualitative impairments in communication, as manifested by at least one of the following:

· a. delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)

· b. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others

· c. stereotyped and repetitive use of language or idiosyncratic language

· d. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

· 3. restricted, repetitive, and stereotyped patterns of behavior, interests, and activities as manifested by at least one of the following:

· a. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus

· b. apparently inflexible adherence to specific, nonfunctional routines or rituals

· c. stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting or complex whole-body movements)

· d. persistent preoccupation with parts of objects

· B. Delays or abnormal function in at least one of the following areas, with onset prior to age 3 years:

· 1. social interaction,

· 2. language as used in social communication,

· 3. symbolic or imaginative play.

· C. The disturbance is not better accounted for by Rhett’s disorder or childhood disintegrative disorder.

(Reprinted with permission from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 1994 American Psychiatric Association.)

The diagnosis depends on various factors. Clients do not have to meet all the criteria to receive the diagnosis; this system allows for individual manifestations of the diagnosis. Since the DSM is a way of classifying all types of mental disorders, most agencies have a copy of it.

The Diagnosis section of the report may be followed by a Prognosis section—a statement about future behavior. The Recommendations conclude the report and suggest some possible courses of action that would be beneficial in the psychologist’s opinion, based on the psychological evaluation. For an example of a psychological report, see  Figure 8.2 .

Psychological evaluations differ according to the client’s needs. The client profiled in Figure 1 was referred for assessment of his reading problems and to determine his eligibility for special services. The tests administered and the final report would be different if the client had been referred for other reasons (e.g., behavioral problems).

Figure 8.2 Confidential Psychology Report

Social History

For a complete case file, the client’s past history and present situation must be investigated. The person’s past adjustment can give indications of how he or she will adjust in the future. A social history also provides information about the way an individual experiences problems, past problem-solving behaviors, developmental stages, and interpersonal relationships. Some of the information in a social history may duplicate what has been gathered during the intake interview. In the social history, however, the client can relate the story in his or her own words, with guidance from the helper.

A social history has a number of advantages. Often, the informal history-taking leaves gaps, and the carefully done social history completes the picture. The helper can then plan the appropriate integration of services and provide better information for future referrals. The social history often includes a better assessment of the client’s need for services; this is especially helpful for clients who have multiple problems. A social history can also fulfill legal requirements. Finally, the process of taking a social history can help build the relationship between the helper and the client.

There are also limitations to the social history. History-taking is a preliminary activity in the helping process, but the client may perceive it as a phase in which solutions are put in place. Unfortunately, categorizations and judgments made at this stage may be premature. The process of taking the history can also give an inaccurate view of what will happen between the client and the helper. Excessive questioning by the helper may lead to a dependent role for the client, and culture-bound questions can create barriers to the development of the helping relationship. In addition, an exhaustive history is not absolutely necessary to develop a plan of services; it may be helpful, but the information gathered may not be relevant to service delivery. Spending too much time on history-taking can also be harmful. The client may use the process to resist significant facts. Other clients may construe it as therapy, but it is not intended as such and may not even be therapeutically valuable. Despite these limitations, the social history still has the important function of completing the case file. Moreover, the helping professional can use certain strategies to mitigate the limitations.

There are several suggestions that can make history-taking, social or otherwise, a positive experience for both the client and the helper. One suggestion is to remember that the client is the main concern, 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. This is a time to continue to build the relationship with the client. Being sensitive to the client’s wishes for privacy or a need to discuss some aspect of his or her history will move the relationship forward. At the same time, it is important for the helper to guide the interview, so maintaining a balance between relationship building and completing the interview is critical.

Using these suggestions, the helper 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.

A 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 how the group influences individual behavior.

Because of group influences, a social history may hold very different meanings for an individual from a collectivist culture than it would for 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 may 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 of 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.

There is no set form or procedure for taking a social history. Some agencies use forms to guide information gathering, such as the social data report shown in  Figure 8.3 . Others just provide guidelines for their helpers, so the length and detail of social histories may vary. In all cases, the social history is prepared when a comprehensive picture of a client’s situation is desired. The outline for writing it depends on what the agency wishes to emphasize, but certain topics are almost always included: identifying data, family relationships, and economic situation. Which other areas are emphasized depends on the focus of the agency and the presenting problem. For example, a social history of a couple involved in marital counseling might target such areas as family relationships and psychosocial development. For someone seeking economic assistance, important areas might be financial status, income, expenses, and work history. In general, the following areas may appear in a social history:

·  Identifying information: Name, address, date and place of birth, Social Security number, military service, parents’ names 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.

Figure 8.3 Social Data Report

The client provides most of the information for a social history, but other sources may also contribute. When the helper has gathered material from sources other than the client, it should be inserted under the appropriate headings, with the source identified. Direct knowledge is the main source, as in the following examples:

· ■ 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 in school.

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

· ■ He was fired from his job for absenteeism.

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

The social history shown in  Figure 8.4  combines two approaches. The Identifying Information section is a form that the helping professional completes. The remaining sections are a narrative based on information compiled from several sources (listed at the end of the report). At this agency, a social history may be compiled by more than one professional, and all who are involved in the writing of the social history sign the written report.

Figure 8.4 Social History

Another way social information appears in a case file is illustrated by the court report shown in  Figure 8.5 . It was prepared for juvenile court, based on social information gathered by a caseworker at the Department of Human Services (DHS). DHS caseworkers frequently prepare court reports, for example, if parental rights are being terminated or if the court asks DHS to investigate a petition for custody. All juvenile court reports have certain things in common, such as the reason for the referral to the department and the circumstances of the child, of both parents, and of the petitioner. Also included is the recommendation of the department, which the court may or may not follow. Although the format of this report is determined by the court, you will see content similarities to the social history in  Figure 8.3 . In this court report, a grandmother is asking for full custody of her granddaughter. A caseworker has been out to the home, completed a social history of the family, and obtained a signed release of information from the petitioner. The caseworker has also consulted with the law enforcement agencies, checked references, and obtained as much information as possible from other sources. The caseworker then writes a report, informing the court as succinctly as possible of all the relevant information gathered.

Figure 8.5 Report for Juvenile Court

Other 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, is 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, mental health specialists, principals, and other helping professionals. Often, the particular information that the helper obtains depends on which source is contacted. Rarely is it gathered in a single report, as medical information might be. In many cases, the helper 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).

Vocational information can be important for several reasons. People seem to be happiest when their activities are satisfying and fulfill their needs. There is also the need to earn a living, and self-support often engenders self-respect. Ways of gathering vocational information range from asking the client about his or her work history to arranging for a formal vocational evaluation. The types of information gathered include jobs previously held, the ability to get along with co-workers, work habits (e.g., punctuality and reliability), and reasons for frequent changes in employment. How much more information is needed depends on the client’s problem and the agency’s mission. For example, if the client has no work experience, an exploration of vocational interests and aptitudes may be in order. For the client who has had varied employment, the focus may shift to attitudes toward work and the skills developed. The client who has a substantial record may need help in reviewing his or her experience and skills to establish a vocational objective.

Let’s return to Roy Johnson’s case, discussed in  Chapter One . Roy’s helper requested a period of vocational evaluation at a regional center that assesses an individual’s vocational capabilities, interests, and aptitudes. Roy and the helper, Tom Chapman, attended a staffing to hear the vocational evaluation report. Mr. Chapman later received a written report (see  Figure 8.6 ). The report illustrates two important points. First, information about a client is integrated with other new information to complete the picture, including work history, medical information, and test scores, as well as the results of the vocational evaluation. Second, this report is a vocational evaluation report. Vocational evaluation is a process of gathering, interpreting, analyzing, and synthesizing all data about a client that has vocational significance and relating it to occupational requirements and opportunities.

Vocational and educational information add other dimensions to the client record, making the case file more complete. This information rounds out the helper’s understanding of who the client is—his or her strengths, weaknesses, abilities, and aptitudes.

Figure 8.6 Vocational Evaluation Report

CHAPTER SUMMARY

The information about the client that is gathered from other professionals assists the helper see a more complete picture of the client. This information includes medical reports, psychological evaluations, social histories, and educational and vocational information. When the helper requests the information from other professionals, the goals must be clear, and it is helpful if the client’s problems are identified. Once the information is received, the helper reviews it and integrates the results with the information previously gathered.

Medical information is critical, especially when a client has disabilities or mental illness. It is important for the helper to understand medical terminology and be familiar with medications. A psychological evaluation is also an important part of a client file because it contributes to the understanding of the client as an individual. Often the helper needs a psychological evaluation to establish eligibility for services, to justify a service, or to screen for criteria to determine need for services.

Social histories provide information about the way an individual experiences problems, past problem-solving behaviors, developmental stages, and interpersonal relationships. The social history can help to complete the picture about the client and assists the building of the relationship between the helping professional and the client.

Other information, such as educational and vocational information, may be included in the file. Relevance is determined by the agency’s mission and services, as well as the client’s problem.

CHAPTER REVIEW

In this chapter you learned some important information about building the case file. A list of key terms and a review of some of the important concepts will assist your understanding of the information in this chapter.

KEY TERMS

Diagnosis

DSM-IV-TR

Medical consultation

Medical diagnosis

Medical terminology

Physical examination

Psychological report

Social history

REVIEWING THE CHAPTER

1.

Identify the resources that will help you understand medical reports.

2.

How does medical information contribute to a case file?

3.

In what situations would a medical consultation help you?

4.

Describe a general medical examination.

5.

Why is keeping current with medical terms a challenge for helpers?

6.

List reasons to refer a client for a psychological evaluation.

7.

How does a helper make a good phraseological referral?

8.

What types of information does a DSM-IV-TR diagnosis provide?

9.

Describe a psychological report.

10.

What is a social history?

11.

Describe the advantages and limitations of a social history.

12.

How will the guidelines for history taking help you complete a social history?

13.

Complete a social data report ( Figure 8.3 ) on yourself.

14.

Write a social history on yourself, using the nine content areas of a social history.

15.

Describe the three ways in which a social history may appear in a case file.

16.

What do vocational and educational information add to a case file?

QUESTIONS FOR DISCUSSION

1.

Why do you think it’s important to have medical information?

2.

What difficulties do you expect to have in understanding a psychological report?

3.

Develop a plan to gather information for a social history of a client who is in prison for armed robbery.

4.

Do you believe that you can have too much information about a client? Why or why not?

REFERENCES

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC: Author.

Dabatos, G., Rondinelli, R. D., & Cook, M. (2000). Functional capacity for impairment rating and disability evaluation. In R. D. Rondinelli & R. T. Katz (Eds.), Impairment rating and disability evaluated (pp. 73–94). Philadelphia: W. B. Saunders.

Felton, J. S. (1992). Medical terminology. In M. G. Brodwin, F. Tellez, & S. K. Brodwin (Eds.), Medical, psychosocial, and vocational aspects of disability (pp. 21–33). Athens, GA: Elliott & Fitzpatric

CHAPTER EIGHT Building a Case File

·  You’re only going to get so much information from just looking at the file. You’re going to know much more when you actually sit down to talk with clients to see what their situation is. And then you will be able to determine what other information would be helpful and from whom.

·  —Social service interviewer, Dearborn, MI

Information from other professionals comes to the helper in two ways. When he or she receives a case file on a client from another agency or worker, it may contain reports or evaluations from other professionals. In other situations, the plan developed by the helper and the client may include referrals to other professionals for evaluations. In both situations, the helper must be able to understand the information provided and (if asking for help from other professionals) to know just what to request. In the example above, the interviewer talks about information available in a client’s file and the need to seek additional information. The client is a good source of the information, as are other agencies and professionals. The case file is continuingly being built.

This chapter examines the types of information that may be found in a case file or that must be gathered to complete one. Exactly what information is needed depends on the individual’s case and the agency’s goals, but many cases involve medical, psychological, social, educational, and vocational information. We introduce each type of information, give a rationale for gathering it, describe the kinds of data likely to be provided, and discuss what the helping professional needs to know in order to make the best use of the report. Review  Figure 8.1  to see the place that building a case file has in the helping process.

For each section of the chapter, you should be able to accomplish the following objectives.

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.

· ■ Describe the type of information provided by the DSM-IV-TR.

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.

Figure 8.1 The Helping Process

Medical Evaluation

Knowledge of medical terminology, conditions, treatments, and limitations is important in understanding a case. Medical information may be provided on a form or in a written report. The exam and report may have been prepared by a general practitioner or by a specialist in a field such as neurology, orthopedics, or ophthalmology. In some cases, the helper can interact with the medical service provider and thus be able to ask questions, request specific assistance, or offer observations. Often, however, he or she does not have this opportunity and must rely on the written report. There are several resources that may prove particularly helpful. Many agencies have a copy of the Physician’s Desk Reference (PDR) or other medical guide. Some also have a physician serving as a consultant, who is available to answer questions. This section introduces basic medical information to help you understand medical terminology.

Agencies approach medical information in different ways. Some require documentation of a mental or physical disability or condition in 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, “the description in a medical report addresses 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” (Dabatos, Rondinelli, & Cook,  2000 , p. 81).

Each medical evaluation includes recommendations that take into account the individual’s physical, emotional, and intellectual capacities. Following 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, limited lifting, and limited need for close work.

Often, however, the form for a general medical examination allows only a small space for the diagnosis, so the helper 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.

Medical Exams

Generally, medical information contributes to a case in two ways.  Medical diagnosis  appraises the general health status of the individual and establishes whether a physical or mental impairment is present. For example, 10-year-old Bobby Jones comes into state custody, abandoned by his parents. The helper in the assessment, care, and coordination team takes Bobby to the health department for an examination. The examination results in a diagnosis of otitis media.

Diagnostic medical services include general medical examinations, psychiatric evaluations, dental examinations, examinations by medical specialists, and laboratory tests. A medical diagnosis is helpful when the client has a medical problem or is currently receiving treatment from a physician, who may provide important information about social and psychological aspects of the case in addition to the medical aspects. When making a referral for a medical diagnosis, the helper should help the client understand why the referral is necessary, the amount of time it will require, what the client can expect to learn, and what use the agency will make of the report.

Medical consultation  is used in several ways. First, the consulting physician can provide an interpretation of medical terms and information. For example, Bobby Jones was diagnosed with otitis media. The helper received this report, asked a colleague what the diagnosis meant, and learned that it was an ear infection. A consultation with a physician would reveal that otitis media is a severe ear infection that sometimes results when the eustachian tubes are not properly angled. The consultation might also explain the report further and clarify possible treatments. In Bobby’s case, the helping professional may need further information about the advantages and disadvantages of two possible treatments: insertion of tubes in the ears and a regimen of antibiotics. A consultation with an otorhinolaryngologist (ear, nose, and throat specialist) could shed light on the medical prognosis and the extent of any hearing disability that might be expected.

The role of a medical consultant is to interpret the available medical data, determine any implications for health and employment, and recommend further medical care if needed. The helper can make the best use of a consultant by being prepared for the meeting, perhaps specifying in writing what is needed from the consultant. This usually involves identifying problems that need to be resolved and setting forth the significant facts of the case. The helper needs to understand medical terminology, the skills of specialists in diagnostic study and treatment programs, and the effects of disability on a client.

The medical service used most often in human services is the  physical examination , in which a physician obtains information concerning a client’s medical history and states the findings. The exam data are entered into the medical record. Here we give an overview of the physical examination: the kinds of information obtained and what the helper needs to know to make such a referral and to understand the physician’s report.

Diagnosis  involves obtaining a complete medical history and conducting a comprehensive physical exam (also called a physical, a health exam, or a medical exam). The results of the exam may be reported on a form provided by the referral source. Sometimes physicians use preprinted schematic drawings of various body parts or organ systems to enhance or clarify the written report. However the information is transmitted, the quality of the reporting depends on the relationship between the physician and the client. In some cases, the client has mixed feelings about the referral for a physical exam. He or she needs an explanation of why the referral is necessary, the amount of time the exam will take, what outcome is expected, and how the information will be used. Keep in mind that the client’s socioeconomic status, language-skill limitations, or cultural background may also influence how he or she feels about the referral. If it is communicated with sensitivity, and if a good relationship with the physician is established, any barriers of anxiety, depression, fear, or guilt can be overcome.

The general medical exam is done by a physician, who takes an overall look at the person’s medical state. Its purpose is to evaluate the person’s current state of health, focusing on two areas. First, a complete medical history records all the factual material, including what the client states and the physician’s inferences from what is not said. A typical starting point is the chief complaint, as expressed by the individual. If there is an illness at present, it is described in terms of onset and symptoms (including location, duration, and intensity). A family history relates significant medical events in the lives of relatives, particularly parents, grandparents, siblings, spouse, and children. Extensive information about the individual’s past medical history is also collected. This may include childhood diseases, serious adult illnesses, injuries, and surgeries. A review of symptoms focuses on information about present and past disorders, which the physician elicits through questions about organs and body systems. After completing the physical exam, the physician records a diagnostic impression. The actual diagnosis is made once there is conclusive evidence, which may mean getting further studies or referring the client to a specialist for consultation.

What exactly makes up a medical exam? Techniques used during a physical exam are inspection, palpation (feeling), percussion (sounding out), and auscultation (listening). Usually, the examining physician works from the skin inward to the body, through various orifices, and from the top of the head to the toes (Felton,  1992 ). Special instruments are used to look, feel, and listen. More time is spent in particular areas to ascertain whether a certain finding truly represents a change in an organ or tissue. Some parts of the exam are carried out quickly, and others require more time. More important areas may receive a second, more thorough examination. The physician records the findings as soon as possible after completing the exam and shares the results with the client.

For some clients, one of the first things that occurs in the helping process is a referral to a physician for a general medical exam. The physician conducts the exam and then he or she completes a form that is sent to the referring helper. It becomes part of the client record.

Medical Terminology

Medical reports often include  medical terminology , which may seem like a foreign language to a helper who is unfamiliar with it, because physicians rely on technical words and phrases for exactness. Medical specialties also have specific terminologies. Other professionals who may write reports using medical terminology are nurses, physical therapists, and occupational therapists. It can be a challenge for the helper to make sense of these reports; he or she must have at least a rudimentary understanding of medical terminology.

It is a continuing challenge for helping professionals to keep current with terminology because of ambiguities, inconsistencies, and the changing course of medical knowledge. Although most word roots have Greek or Latin origins, some occur in both but have different meanings. The root ped, for example, means “child” in Greek (e.g., pediatrician), but in Latin ped means “foot” (e.g., pedicure). Many diseases are named for individuals, such as Alzheimer’s disease and Hodgkin’s disease. Some disorders are called syndromes: Cushing’s syndrome, Horner’s syndrome. Acronyms or abbreviations are formed from the initials of lengthy terms: MRI (magnetic resonance imaging) and ACTH (adrenocorticotropic hormone) are examples. In addition, medical terminology traditionally uses hundreds of abbreviations; some of the most common are listed in  Table 8.1 . Keeping informed about trends in medicine increases one’s understanding of the meanings of terms. For example, physicians increasingly prescribe generic drugs rather than brand names (e.g., diazepam rather than Valium). Keeping current with medical terminology entails awareness of chemicals, syndromes, and diseases that are newly named and sometimes given acronyms or abbreviations (e.g., AIDS for acquired immunodeficiency syndrome). It must also be remembered that words can have multiple meanings and that several names may apply to a single entity.

TABLE 8.1 Medical Abbreviations

Abbreviation	Meaning	Abbreviation	Meaning
a.c.	before meals	L-1, L-2, L-3	lumbar vertebrae (by number)
b.i.d.	twice daily	LLQ	left lower quadrant
B.P.	blood pressure	LMP	last menstrual period
C-1, C-2, C-3	cervical vertebrae (by number)	p.c.	after meals
CBC	complete blood count	p.r.n.	as needed
CNS	central nervous system	q.i.d.	four times daily
DX	diagnosis	RLQ	right lower quadrant
F.H.	family history	RX	treatment
GI	gastrointestinal	S-1, S-2, S-3	sacral vertebrae (by number)
GU	genitourinary	T-1, T-2, T-3	thoracic vertebrae (by number)
HDL	high-density lipoprotein	t.i.d.	three times daily
h.s.	at bedtime	WBC	white blood count
H & P	history and physical examination

Psychological Evaluation

The objective of a psychological evaluation is to contribute to the understanding of the individual who is the subject. The report writer is a consultant who makes a psychological assessment that is practical, focused, and directed toward the solution of a problem. The psychological report he or she prepares is more than a presentation of data. This section helps you determine when a psychological evaluation is needed, how to make the referral, and how to prepare the client. The evaluation itself and the report are also discussed.

Referral

Helping professionals may refer clients for psychological evaluations for a number of reasons. One reason is to establish a diagnosis in order to meet criteria of eligibility for services.

·  Nadine is a deeply depressed 15-year-old who is currently taking antidepressant medication. She is increasingly out of control. Yesterday, she slapped her grandmother, with whom she lives, and threatened to kill her. If she is to receive services in an inpatient treatment program, she must have a diagnosis confirming emotional disturbance.

Another reason for a psychological evaluation is to provide justification for a particular service.

·  Amal is a 28-year-old male whose divorce will be final in a month. As the court date approaches, Amal feels more and more depressed. He is having trouble getting up in the morning, showing up for work on time, and maintaining relationships with those who are close to him. His physician has suggested counseling, but Amal’s insurance company insists that he have a psychological evaluation to determine whether or not he needs it.

Sometimes a psychological evaluation functions as a screening or routine evaluation to obtain information about a client’s personality, aptitude, interests, intelligence, and achievement.

·  Greg is a 35-year-old male who is the only child of elderly parents. He is cognitively impaired. His parents, concerned about who will care for Greg if something happens to them, have learned of a group home where the residents live under close supervision. One requirement for acceptance into the program is a recent psychological evaluation that assesses intelligence as well as ability to function independently.

A helper may also order a psychological evaluation to resolve contradictions or ambiguities or to add information that is missing.

·  Paloma is a 10-year-old who is enrolled in public school. Her teacher is concerned about her behavior. One day she is passive, rarely interacts with her classmates, and does not participate in class. The next day, she may be loud, talkative, and disruptive. Just yesterday, she started a fight with a classmate. This has prompted her teacher to request an evaluation from the school psychologist.

Finally, a psychological evaluation may be recommended to answer particular questions regarding the client. Is there brain damage? Why does the individual have trouble relating to others? How is this person adjusting to the recent amputation of her leg? Why is the client doing poorly in school?

In any of these situations, a referral for a psychological evaluation is appropriate. In each case, the professional seeks help in order to provide the client with needed services. It is easiest to get what is needed if the consulting psychologist knows the general mission of the agency and understands the specific problem to be addressed. Having this information allows him or her to choose the most relevant and efficient approach to gathering the needed information. The referral for a psychological evaluation is usually made by a helping professional, who specifies what is needed: a routine workup, testing, questions about the case, a diagnosis. Thus, the psychologist is charged with a mission. It is therefore critical that the referral be more than a general request, such as “psychological evaluation” or “for psychological testing.” These terms communicate poorly; the referring professional has failed to express what prompted the referral. Two scenarios may result: The psychologist may ask the helper for more specific information, or he or she may try to guess what is wanted or needed. When the reason for the referral is not clear, it is difficult for the psychologist to provide a useful report.

How does a helper make a good psychological referral? First, it is important to be clear about the reason for referral. The helping professional must clarify the need for documentation of a condition or disability, obtaining test scores, or the exploration of behavioral inconsistencies. Specific questions also help the psychologist focus on the client’s problems. The psychologist then makes recommendations to the helper. The two professionals can discuss the case before the evaluation to clear up any questions or needs. Since 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 helper 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 helper considers them crazy. Demystifying the evaluation helps to dispel these attitudes.

The 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.

One of the primary ways that a psychologist observes current behavior is by testing. From the discussion of testing in the previous chapter, you know that testing gives samples of behavior. That discussion also introduced a number of tests that are useful in human services. Psychologists use many of them, notably the WAIS and projective tests (such as the Rorschach and Thematic Apperception Test). These tests are individually administered and scored, and psychologists are specially trained to use them. As a consultant, then, the psychologist decides what kinds of data must be gathered to carry out the assignment given by the referral source, which findings have relevance, and how these findings can be most effectively presented.

The results of the psychological evaluation are communicated to the helper in a written report. The psychological report  is a written document that explains an individual’s personal characteristics, mental status, and social history. This document provides information that helps determine what are the problems and challenges facing the client and what might be possible interventions. The report may appear in one of several forms, the most common of which is a narrative (illustrated by the report included in this section).

Results may also be communicated as a terse listing of problems and proposed solutions. Another option is the computer-generated report, usually consisting of a sequence of statements or a profile of characteristics. Less frequently used are checklists of statements or adjectives, clinical notes, and oral reports relating impressions. Since the narrative is the form of psychological report that is most often used in human services, let’s explore it further.

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 classification system for diagnoses used in the United States is published by the American Psychological Association in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,Text Revision (American Psychiatric Association,  2000 ). Many helping professionals receive reports based upon a  DSM-IV-TR  diagnosis. Understanding what the various diagnoses and scores mean will support the helper’s understanding of the challenges the clients face. At times, professionals will submit a DSM-IV-TR diagnosis and a treatment plan. After consulting with the professional, the helper may provide supportive services. Let’s see what types of information a DSM-IV-TR diagnosis provides.

The DSM-IV-TR codes include a broad range of psychological disorder categories, such as adjustment disorders, substance abuse, attention-deficit/hyperactivity disorder, cocaine use, major depressive disorder, and schizophrenia. The DSM-IV-TR uses a multi-diagnostic approach that helps assess clients using multiple factors. There are five axes used in the diagnostic system.

Axis I focuses on disorders known as “clinical syndromes.” This means that there is a cluster or a group of symptoms that exist for several particular disorders. Clinical syndromes include the following:

· ■ Disorders usually first diagnosed in infancy, childhood, or adolescence

· ■ Organic Mental Disorders

· ■ Substance-Related Disorders

· ■ Schizophrenia and other Psychotic Disorders

· ■ Mood Disorders

· ■ Anxiety Disorders

· ■ Somatoform Disorders

· ■ Dissociative Disorders

· ■ Sexual and Gender-Identity Disorders

· ■ Eating Disorders

· ■ Sleep Disorders

Axis II provides a framework to help professionals identify individuals with personality disorders. An Axis II diagnosis indicates that an individual has a personality trait(s) for a long period of time. These traits restrict the individual’s positive interaction with others and limit the individual’s success in social and work situations. Axis II also includes Mental Retardation. Axis II diagnoses include:

· ■ Paranoid Personality Disorder

· ■ Schizoid Personality Disorder

· ■ Antisocial Personality Disorder

· ■ Borderline Personality Disorder

· ■ Histrionic Personality Disorder

· ■ Obsessive-Compulsive Personality Disorder

· ■ Mental Retardation

Axis III includes General Medical Conditions that may be related to the diagnoses in the other axes. At times the mental disorder is a direct result of the medical condition. Other times, the medical condition exacerbates the disorder. Sometimes one or more of the symptoms of the disorder are related to the medical condition. Diseases that are components of the General Medical Conditions are listed below.

· ■ Infectious and Parasitic Diseases

· ■ Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders

· ■ Diseases of the Blood and Blood-Forming Organs

· ■ Diseases of the Circulatory System

· ■ Diseases of the Respiratory System

· ■ Diseases of the Digestive System

TABLE 8.2 Excerpt from the DSM-IV-TR: Codes for Adjustment Disorders and Attention-Deficit/Hyperactivity Disorder

·  Adjustment Disorder ·  309.0 With Depressed Mood ·  309.24 With Anxiety ·  309.28 With Mixed Anxiety and Depressed Mood ·  309.3 With Disturbance of Emotions and Conduct ·  309.9 Unspecified ·  Attention-Deficit/Hyperactivity Disorder ·  314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type ·  314.00 Attention-Deficit/Hyperactivity Disorder, Predominately Inattentive Type ·  314.01 Attention-Deficit/Hyperactivity Disorder, Hyperactive-Impulsive Type

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 2000 American Psychiatric Association.

Axis IV provides an opportunity for the professional to list Psychosocial and Environmental Problems related to the diagnosis and the treatment. These factors include problems in living, family and other relationships, and social support. Also included are work related difficulties, financial problems, access to needed services, and legal difficulties.

Axis V is a Global Assessment of Functioning (GAF) Scale. At this time the professional assesses the individual’s overall ability to function in interpersonal, social, occupational, and family settings. Many professionals will provide this one score at the beginning of treatment, during treatment, at the end of treatment, and during follow-up to assess the client’s progress. The scale rates the individual from 100 to 1. A rating of 100-91 means that the individual is able to cope well in multiple circumstances. A rating of 50-41 indicates that the individual demonstrates an inability to function in arenas such as family and work. A rating of 10-1 means the individual is dangerous to self and other.

Reading diagnostic criteria from the DSM-IV-TR helps you understand how the professional makes the diagnosis. For example,  Table 8.2  presents a detailed list of adjustment disorders and attention-deficit/hyperactivity disorders taken from the DSM-IV-TR. This information illustrates the range of disorders that an individual may experience. The professional believes that the more accurate the diagnosis, the more closely the treatment can be matched to the individual’s experience.

As stated earlier, the DSM-IV-TR describes criteria for specific disorders. The following is an excerpt from the DSM-IV-TR that establishes the criteria for a diagnosis of autistic disorder (American Psychiatric Association,  2000 , pp.70–71). 299.00 Autistic Disorder

· A. A total of six (or more) items from 1, 2, and 3, with at least two from 1, and one each from 2 and 3:

· 1. qualitative impairment in social interaction, as manifested by at least two of the following:

· a. marked impairment in the use of multiple nonverbal behaviors, such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction

· b. failure to develop peer relationships appropriate to developmental level

· c. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)

· d. lack of social or emotional reciprocity

· 2. qualitative impairments in communication, as manifested by at least one of the following:

· a. delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)

· b. in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others

· c. stereotyped and repetitive use of language or idiosyncratic language

· d. lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level

· 3. restricted, repetitive, and stereotyped patterns of behavior, interests, and activities as manifested by at least one of the following:

· a. encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus

· b. apparently inflexible adherence to specific, nonfunctional routines or rituals

· c. stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting or complex whole-body movements)

· d. persistent preoccupation with parts of objects

· B. Delays or abnormal function in at least one of the following areas, with onset prior to age 3 years:

· 1. social interaction,

· 2. language as used in social communication,

· 3. symbolic or imaginative play.

· C. The disturbance is not better accounted for by Rhett’s disorder or childhood disintegrative disorder.

(Reprinted with permission from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 1994 American Psychiatric Association.)

The diagnosis depends on various factors. Clients do not have to meet all the criteria to receive the diagnosis; this system allows for individual manifestations of the diagnosis. Since the DSM is a way of classifying all types of mental disorders, most agencies have a copy of it.

The Diagnosis section of the report may be followed by a Prognosis section—a statement about future behavior. The Recommendations conclude the report and suggest some possible courses of action that would be beneficial in the psychologist’s opinion, based on the psychological evaluation. For an example of a psychological report, see  Figure 8.2 .

Psychological evaluations differ according to the client’s needs. The client profiled in Figure 1 was referred for assessment of his reading problems and to determine his eligibility for special services. The tests administered and the final report would be different if the client had been referred for other reasons (e.g., behavioral problems).

Figure 8.2 Confidential Psychology Report

Social History

For a complete case file, the client’s past history and present situation must be investigated. The person’s past adjustment can give indications of how he or she will adjust in the future. A social history also provides information about the way an individual experiences problems, past problem-solving behaviors, developmental stages, and interpersonal relationships. Some of the information in a social history may duplicate what has been gathered during the intake interview. In the social history, however, the client can relate the story in his or her own words, with guidance from the helper.

A social history has a number of advantages. Often, the informal history-taking leaves gaps, and the carefully done social history completes the picture. The helper can then plan the appropriate integration of services and provide better information for future referrals. The social history often includes a better assessment of the client’s need for services; this is especially helpful for clients who have multiple problems. A social history can also fulfill legal requirements. Finally, the process of taking a social history can help build the relationship between the helper and the client.

There are also limitations to the social history. History-taking is a preliminary activity in the helping process, but the client may perceive it as a phase in which solutions are put in place. Unfortunately, categorizations and judgments made at this stage may be premature. The process of taking the history can also give an inaccurate view of what will happen between the client and the helper. Excessive questioning by the helper may lead to a dependent role for the client, and culture-bound questions can create barriers to the development of the helping relationship. In addition, an exhaustive history is not absolutely necessary to develop a plan of services; it may be helpful, but the information gathered may not be relevant to service delivery. Spending too much time on history-taking can also be harmful. The client may use the process to resist significant facts. Other clients may construe it as therapy, but it is not intended as such and may not even be therapeutically valuable. Despite these limitations, the social history still has the important function of completing the case file. Moreover, the helping professional can use certain strategies to mitigate the limitations.

There are several suggestions that can make history-taking, social or otherwise, a positive experience for both the client and the helper. One suggestion is to remember that the client is the main concern, 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. This is a time to continue to build the relationship with the client. Being sensitive to the client’s wishes for privacy or a need to discuss some aspect of his or her history will move the relationship forward. At the same time, it is important for the helper to guide the interview, so maintaining a balance between relationship building and completing the interview is critical.

Using these suggestions, the helper 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.

A 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 how the group influences individual behavior.

Because of group influences, a social history may hold very different meanings for an individual from a collectivist culture than it would for 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 may 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 of 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.

There is no set form or procedure for taking a social history. Some agencies use forms to guide information gathering, such as the social data report shown in  Figure 8.3 . Others just provide guidelines for their helpers, so the length and detail of social histories may vary. In all cases, the social history is prepared when a comprehensive picture of a client’s situation is desired. The outline for writing it depends on what the agency wishes to emphasize, but certain topics are almost always included: identifying data, family relationships, and economic situation. Which other areas are emphasized depends on the focus of the agency and the presenting problem. For example, a social history of a couple involved in marital counseling might target such areas as family relationships and psychosocial development. For someone seeking economic assistance, important areas might be financial status, income, expenses, and work history. In general, the following areas may appear in a social history:

·  Identifying information: Name, address, date and place of birth, Social Security number, military service, parents’ names 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.

Figure 8.3 Social Data Report

The client provides most of the information for a social history, but other sources may also contribute. When the helper has gathered material from sources other than the client, it should be inserted under the appropriate headings, with the source identified. Direct knowledge is the main source, as in the following examples:

· ■ 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 in school.

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

· ■ He was fired from his job for absenteeism.

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

The social history shown in  Figure 8.4  combines two approaches. The Identifying Information section is a form that the helping professional completes. The remaining sections are a narrative based on information compiled from several sources (listed at the end of the report). At this agency, a social history may be compiled by more than one professional, and all who are involved in the writing of the social history sign the written report.

Figure 8.4 Social History

Another way social information appears in a case file is illustrated by the court report shown in  Figure 8.5 . It was prepared for juvenile court, based on social information gathered by a caseworker at the Department of Human Services (DHS). DHS caseworkers frequently prepare court reports, for example, if parental rights are being terminated or if the court asks DHS to investigate a petition for custody. All juvenile court reports have certain things in common, such as the reason for the referral to the department and the circumstances of the child, of both parents, and of the petitioner. Also included is the recommendation of the department, which the court may or may not follow. Although the format of this report is determined by the court, you will see content similarities to the social history in  Figure 8.3 . In this court report, a grandmother is asking for full custody of her granddaughter. A caseworker has been out to the home, completed a social history of the family, and obtained a signed release of information from the petitioner. The caseworker has also consulted with the law enforcement agencies, checked references, and obtained as much information as possible from other sources. The caseworker then writes a report, informing the court as succinctly as possible of all the relevant information gathered.

Figure 8.5 Report for Juvenile Court

Other 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, is 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, mental health specialists, principals, and other helping professionals. Often, the particular information that the helper obtains depends on which source is contacted. Rarely is it gathered in a single report, as medical information might be. In many cases, the helper 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).

Vocational information can be important for several reasons. People seem to be happiest when their activities are satisfying and fulfill their needs. There is also the need to earn a living, and self-support often engenders self-respect. Ways of gathering vocational information range from asking the client about his or her work history to arranging for a formal vocational evaluation. The types of information gathered include jobs previously held, the ability to get along with co-workers, work habits (e.g., punctuality and reliability), and reasons for frequent changes in employment. How much more information is needed depends on the client’s problem and the agency’s mission. For example, if the client has no work experience, an exploration of vocational interests and aptitudes may be in order. For the client who has had varied employment, the focus may shift to attitudes toward work and the skills developed. The client who has a substantial record may need help in reviewing his or her experience and skills to establish a vocational objective.

Let’s return to Roy Johnson’s case, discussed in  Chapter One . Roy’s helper requested a period of vocational evaluation at a regional center that assesses an individual’s vocational capabilities, interests, and aptitudes. Roy and the helper, Tom Chapman, attended a staffing to hear the vocational evaluation report. Mr. Chapman later received a written report (see  Figure 8.6 ). The report illustrates two important points. First, information about a client is integrated with other new information to complete the picture, including work history, medical information, and test scores, as well as the results of the vocational evaluation. Second, this report is a vocational evaluation report. Vocational evaluation is a process of gathering, interpreting, analyzing, and synthesizing all data about a client that has vocational significance and relating it to occupational requirements and opportunities.

Vocational and educational information add other dimensions to the client record, making the case file more complete. This information rounds out the helper’s understanding of who the client is—his or her strengths, weaknesses, abilities, and aptitudes.

Figure 8.6 Vocational Evaluation Report

CHAPTER SUMMARY

The information about the client that is gathered from other professionals assists the helper see a more complete picture of the client. This information includes medical reports, psychological evaluations, social histories, and educational and vocational information. When the helper requests the information from other professionals, the goals must be clear, and it is helpful if the client’s problems are identified. Once the information is received, the helper reviews it and integrates the results with the information previously gathered.

Medical information is critical, especially when a client has disabilities or mental illness. It is important for the helper to understand medical terminology and be familiar with medications. A psychological evaluation is also an important part of a client file because it contributes to the understanding of the client as an individual. Often the helper needs a psychological evaluation to establish eligibility for services, to justify a service, or to screen for criteria to determine need for services.

Social histories provide information about the way an individual experiences problems, past problem-solving behaviors, developmental stages, and interpersonal relationships. The social history can help to complete the picture about the client and assists the building of the relationship between the helping professional and the client.

Other information, such as educational and vocational information, may be included in the file. Relevance is determined by the agency’s mission and services, as well as the client’s problem.

CHAPTER REVIEW

In this chapter you learned some important information about building the case file. A list of key terms and a review of some of the important concepts will assist your understanding of the information in this chapter.

KEY TERMS

Diagnosis

DSM-IV-TR

Medical consultation

Medical diagnosis

Medical terminology

Physical examination

Psychological report

Social history

REVIEWING THE CHAPTER

1.

Identify the resources that will help you understand medical reports.

2.

How does medical information contribute to a case file?

3.

In what situations would a medical consultation help you?

4.

Describe a general medical examination.

5.

Why is keeping current with medical terms a challenge for helpers?

6.

List reasons to refer a client for a psychological evaluation.

7.

How does a helper make a good phraseological referral?

8.

What types of information does a DSM-IV-TR diagnosis provide?

9.

Describe a psychological report.

10.

What is a social history?

11.

Describe the advantages and limitations of a social history.

12.

How will the guidelines for history taking help you complete a social history?

13.

Complete a social data report ( Figure 8.3 ) on yourself.

14.

Write a social history on yourself, using the nine content areas of a social history.

15.

Describe the three ways in which a social history may appear in a case file.

16.

What do vocational and educational information add to a case file?

QUESTIONS FOR DISCUSSION

1.

Why do you think it’s important to have medical information?

2.

What difficulties do you expect to have in understanding a psychological report?

3.

Develop a plan to gather information for a social history of a client who is in prison for armed robbery.

4.

Do you believe that you can have too much information about a client? Why or why not?

REFERENCES

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC: Author.

Dabatos, G., Rondinelli, R. D., & Cook, M. (2000). Functional capacity for impairment rating and disability evaluation. In R. D. Rondinelli & R. T. Katz (Eds.), Impairment rating and disability evaluated (pp. 73–94). Philadelphia: W. B. Saunders.

Felton, J. S. (1992). Medical terminology. In M. G. Brodwin, F. Tellez, & S. K. Brodwin (Eds.), Medical, psychosocial, and vocational aspects of disability (pp. 21–33). Athens, GA: Elliott & Fitzpatric

CHAPTER TEN Coordinating Services

·  One of the exciting parts of our work is the progress you make with a client but then they disappear. You make all kinds of arrangements for them—housing, counseling, doctor’s appointments. And they just disappear. So the plan doesn’t work and you move on to something else. Two months later here they are again.

·  —AIDS worker, Atlanta

Implementing the service plan follows its development. Often, however, those we serve require assistance that we are not able to provide. For example, the helper may not have the necessary expertise to address the problem, the mission of the agency may impose limitations, or perhaps there are insufficient resources. It is at this point that coordinating services provided by other professionals and other agencies is necessary and appropriate. The situation that introduces this chapter illustrates not only the range of services that may be necessary but also the challenges of following through with the referral.

This chapter focuses on service coordination and describes the knowledge and skills that are necessary to implement the components of a service plan that involves other professionals and other agencies. They include making referrals, monitoring service delivery, and working with other professionals. You can review  Figure 10.1  to see where coordinating services occurs in the helping process. The chapter also provides a number of examples and descriptions of clients and situations. After reading this chapter, you should be able to accomplish the following objectives:

Service Coordination

· ■ List the advantages of coordinating services with other agencies and professionals.

· ■ Describe a systematic selection process for resources.

· ■ List ways to achieve more effective communication with other professionals.

Referral

· ■ Describe the broker role.

· ■ Make an appropriate referral.

· ■ Identify the activities involved in monitoring.

Monitoring Services

· ■ Describe the helper’s role in monitoring services.

· ■ List the questions that guide monitoring activities.

Figure 10.1 The Helping Process

Coordinating Services

In the event that a client needs services that an agency does not provide, it is the helper’s responsibility to locate such resources in the community, arrange for the client to make use of them, and support the client in using them. These are the three basic activities in coordinating human service delivery. In  coordinating services , the helper engages in linking, monitoring, and advocating, while building on the assessment and planning that have taken place in earlier phases of the helping process. The helper continues to build on client strengths and emphasizes client empowerment, continually aware of the client’s cultural background and the client’s basic values.

Coordinating the services of multiple professionals has a number of advantages, for both the helper and the client. First, the client gains access to an array of services, since no single agency can meet all the needs of all clients. The helper can concentrate on providing only those services for which he or she is trained, while linking the client to the services of other professionals who have different areas of expertise and the necessary resources. Second, the helper’s knowledge and skills help the client gain access to needed services. Often, services are available in the community, but clients are unlikely to know what they are or how to get them. The success of service delivery may depend on advocacy by the helper. Also, service coordination promotes effective and efficient service delivery. In times of shrinking resources, demands for cutbacks in social services, and stringent accountability, service provision must be cost effective and time limited. In addition, customer satisfaction is important. Clients have a right to receive the services they need without getting shuffled from agency to agency or experiencing confusion as they try to coordinate their own care.

Service coordination becomes key once the client and the helper have agreed on a plan of services and determined what services will be provided by someone other than the helper. For services that will be provided by others, a beginning step is to review previous contacts with service providers. What services do they provide? Is this client eligible for those services? Can the services be provided in-house? What about the individual’s own resources and those of the family? Family support may be critical for the success of the plan, or the client’s own problem-solving skills may be helpful. A helping professional who is thorough will not ignore the resources of the client, the family, or significant others. The next step is referral —the connection of a client with a service provider. The final step is monitoring service delivery over time and following up to ensure the service has been delivered appropriately. These steps may vary somewhat, depending on whether the services are delivered in-house or by an outside agency, but the flow of the process is likely to be the same.

TABLE 10.1 Interagency Service Plan

Joyce and Jim Elysia Roberto Renee Ming	Parents Pediatric Nurse Child Specialist Social Worker Educational specialist
Identified outcomes	Plan	Person responsible
1.	Jim and Joyce will learn how to work with Cindy, their 5 year old daughter	a.	Assessment completed	Ming
	b.	Referral made to educational institutions	Jim and Joyce
	c.	Help Jim and Joyce structure the environment at home	Ming
	d.	Schedule follow up visits with professionals	Roberto
2.	Jim and Joyce will learn about services available	a.	Jim and Joyce receive web address of resource directory	Renee
	b.	Public school contacts will be made	Jim and Joyce
3.	Provide financial resources	a.	Social work office will support this effort	Renee
4.	Jim and Joyce receive continuing education about Cindy’s condition	a.	Schedule visits with Roberto	Roberto
	b.	Learn about books and web resources	Ming

An example of client care that involves multiple professionals is two-year-old Cindy, who has recently been diagnosed with autism. The initial plan for Jim and Joyce, Cindy’s parents, indicates the various services that they will need ( Table 10.1 ). This is an initial plan that will develop and change as Jim and Joyce work with Cindy and as Cindy’s developmental needs change.

Client participation is important throughout the service coordination process. This entails more than just keeping the client informed; his or her involvement should be active and ongoing. The values, preferences, strengths, and interests of the client play a key role in selecting community resources, and of course client participation is critical in following up on a referral. Clients also have the right to privacy and confidentiality. Without the client’s written consent, the helper must not involve others in the case or give any outsider information about it.

Resource Selection

Once a client’s needs and corresponding services have been identified, the client and the helper turn their attention to  resource selection —selecting individuals, programs, or agencies that can meet those needs. Paramount in this decision is consideration of the client’s values and preferences. The information and referral system the helper has developed is useful in this regard.

·  Rube Manning is a 53-year-old white male who is on parole for aggravated rape. He had sexual relations with his 12-year-old niece; she later gave birth to his son. Both parties claim that the intercourse was consensual; the severity of the charge and conviction was due to the girl’s age. The girl and the family seem to harbor no animosity toward Rube, going so far as to write a letter on his behalf to the Department of Corrections. Rube was sentenced to three years in prison and is now eligible for parole. Angela Clemmons is the parole officer assigned this case. She and Rube must develop a plan of services for him to pursue once he is released. Among the conditions of Rube’s parole are completing a mandatory sex offender program, supporting his son, and finding employment.

There are no options for the mandatory sex offender program; there is only one available in this community. Angela senses that Rube is motivated to do everything in his power to comply with the conditions of parole. Although he does not talk much about his prison experience, he does say that he didn’t like it. Angela suspects that he was abused by other inmates. Sex offenders are usually on the lower rungs of the prisoner hierarchy unless they are very strong or charismatic; Rube is neither.

Finding employment and supporting the child are tied together. Checking her information and referral file, Angela advises Rube that there are three short-term training programs that will provide him with job skills. The first two are at the vocational school and would give him a certificate in either horticulture or industrial maintenance. The third one is on-the-job training in food services, with a modest salary until training is finished. Rube’s preference is horticulture, because he grew up on a farm and thinks he would feel more comfortable outdoors. He knows that industrial maintenance is a fancy term for janitorial work, and he’s not interested. The location of the food services training is not on the bus line, and Rube has no transportation of his own, but this option offers a salary immediately. Angela notices that Rube sounds interested—even a little excited—about horticulture, so she checks her addresses and e-mail file for the phone number of her contact (see  Figure 10.2 ).

In this case, resource selection has been systematic, which has advantages for both the client and the helper. They are then able to proceed objectively and deliberately, taking into account Rube’s values, beliefs, and desires. The rationale for the choice is articulated, and it will reinforce his motivation to follow through with the referral. Rube Manning and his parole officer have chosen the horticulture program: it is on the bus line, it builds on Rube’s previous farming experience, and it is something he wants to pursue.

The selection process can also accommodate many alternatives and can tailor services to the client’s unique circumstances. The conditions of Rube’s parole include work, and he does want the independence, salary, and respect that come with employment. However, he is not willing to do just anything. Being a janitor doesn’t appeal to him, and he does not want to work indoors. Had the parole officer ignored his feelings at this point and decided to steer him toward janitorial work, Rube probably would not be motivated to do well. At the very worst, he would do nothing, and his parole would be revoked. In addition, the relationship between Angela Clemmons and Rube Manning would not develop as a partnership. Instead, their decision to try the horticultural program takes into account Rube’s wishes, along with his need for training and employment.

Being aware of the client’s preferences, strengths, and values is critical to the success of the selection step in service coordination. There must be a strong partnership between the participants.

Figure 10.2 Entry in Information and Referral File

Working with Other Professionals

Clearly, effective service coordination depends to a certain extent on the helper’s relationship with other professionals. The professionals on whom a helper relies have a wide variety of cultural backgrounds, academic achievements, and job descriptions. Often, barriers appear to service coordination that are rooted in turf issues, competition for clients, and concern about confidentiality. Communication, sometimes a challenge among those with different perspectives, is one way of addressing these barriers.

Good communication skills are critical when working with personnel from other agencies. These skills can be the deciding factor in making effective use of resources on the client’s behalf. Suggestions for enhancing communication with other helpers include the following. First, avoid stereotyping other professionals. You may have encountered one nurse who was rude, but it is unreasonable to think that all nurses are that way. Second, don’t hesitate to ask for clarification or a definition of terminology that you don’t understand. It is better to ask than to pretend you know. Third, you can help others learn your own terminology by using it and explaining its meaning. Finally, be aware that other professionals may well have different styles of communication. For example, a clinical style may be more comfortable for psychiatrists. Other styles that have been identified are legal (of equal adversaries), political (of unequal adversaries), and pedagogical (teacher–student).

Referral

As mentioned earlier, no helper can provide all conceivable services. Therefore, arrangements must often be made to match client needs with resources. This is done by referring the client to another helping professional or agency to obtain the needed services. Referral is the process that puts the client in touch with needed resources. A human service professional in East Los Angeles, working with parents of students at an urban high school puts it like this: “We realize how many individuals there are in a family and a limited source of income and we refer them to services . . . we have some hotlines that we can refer them to and often the Department of Social Services. Of course I refer them to the churches, too. They have places for homeless and shelters and things like that.”

A referral connects the client with a resource within the agency structure or at another agency. In no way does referral imply failure on the helper’s part. Limitations on the services a helper can personally provide are imposed by policy, rules, regulations, and structure, as well as his or her own expertise or personal values.

The  broker  role is useful at this point in service coordination. The broker knows both the resources available in the community and the policies and procedures of agencies. He or she acts as a go-between for those who seek services and those who provide them. Consider the following case with regard to the referral process and the broker role.

·  Bethany’s first client on Tuesday is Anna, a young woman who has just discovered that she is pregnant. This pregnancy has caused a crisis in Anna’s family. Her parents are first generation immigrants from San Salvador, Catholic, and adamantly opposed to both the pregnancy and abortion. Although the agency that employs Bethany specializes in career development services, Anna feels comfortable with Bethany and wishes to discuss her options about the pregnancy with her. On the other hand, this is a difficult subject for Bethany, because her sister had an abortion three years ago and still feels guilty and upset about her decision. In fact, the whole family is still having difficulty with it, since the sister is living at home. Bethany also is aware that her training is in career development, and she has never worked with anyone dealing with an unwanted pregnancy.

The encounter illustrates a situation that is appropriate for a referral. Bethany has some personal feelings that may impair her objectivity; she recognizes that she has no professional experience with this problem; and her agency’s purpose is career development. For these reasons, she decides it is best to make a referral to someone who can help Anna explore options related to the pregnancy. Bethany will continue to support Anna’s career development efforts. In the referral process, Bethany’s role is that of a broker.

Making a referral may seem like a fairly uncomplicated process, but it often results in failure. If a helper believes that all that is necessary is being aware of client needs and making a phone call, the referral is likely to be unsuccessful. In fact, it is common for clients referred to other community resources to resist making the initial contact. Clients may also fail to follow through after the first interview and drop out before service provision is complete.

There are three reasons for the failure of a referral. The first is insensitivity to client needs on the helper’s part. Identifying the problem but failing to grasp the client’s feelings about it contributes to an unsuccessful referral. The client may not be ready for referral at this point, feeling only that he or she is being shuffled among workers or agencies. Second, if the helper lacks knowledge about resources, the client may be referred to the wrong resource. This makes him or her feel lost in the system, think that it is all a waste of time, and believe (sometimes correctly) that the helper is incompetent. A third reason for failure is misjudging the client’s capability to follow through with the referral. Suggesting to an involuntary client that she call to make an appointment for a physical examination may not work, perhaps because she is new to town, is unsure who to call, doesn’t have a phone, or may not even want this exam.

How can the helper make the referral process a successful one? Assessing clients’ capabilities means finding out how much they can do on their own. It is good to encourage independence and self-sufficiency in clients, but some of them will be unable to identify what they need and take the steps to obtain it. The nature of the problem, the feelings the client has about it, and the energy required for action may all contribute to feelings of loneliness, an inability to act, and a lack of motivation to follow through.

In addition to assessing the client’s capabilities, the referring helper must form a clear idea of what role he or she will play in the referral process. In this, the helper should be guided by what the client needs and what relationship the helper has with the other professional or agency. The helper’s degree of involvement in the referral can fall anywhere on a continuum—from discussing several resources with the client, who then takes responsibility for selecting a resource and following through, to giving concrete assistance with details such as making the appointment on the client’s behalf and having an agency volunteer accompany him or her to the appointment.

Bethany approached the referral process in the following way. She acknowledged Anna’s concern about her situation and recognized her desire for some help. She also shared with Anna her reservations about being able to assist her, explaining that her training was in career development and she had limited knowledge about options for an unmarried pregnant woman. However, she did know of two agencies that offered just the services Anna was seeking. Anna wanted to know about these, so they discussed the services they provide and their geographic location. Anna was concerned about the cost of services, and Bethany was unsure about the agencies’ charges. Then she checked her computer file and found that both agencies charged fees on a sliding scale. Anna didn’t know what that meant, so Bethany explained that such a scale determined the fee in accordance with the individual’s income. Anna was unsure how to get an appointment—who to call, how to explain the problem, and so forth. She also wondered whether she would be able to continue working with Bethany on career development. Bethany discussed all of these concerns with Anna. Together, they decided on one of the agencies, and Bethany agreed to make the initial contact. Her previous work with Anna led her to believe that once the initial anxiety of making contact was over, Anna was capable of showing up for the appointment and getting the services she needed.

·  BETHANY: Hello. This is Bethany Douglas at Career Development. I am working with a client who needs help identifying her options with an unplanned pregnancy. Will someone at your agency see her?

·  RECEPTIONIST: We do provide counseling. Let me connect you with one of our helpers.

·  HELPER: Hello, this is Carol Fong. May I help you?

·  BETHANY: Yes, Bethany Douglas here. I am a career professional at Career Development. My client has just found out she is pregnant and would like to talk with someone about her options. She is 19 and single. Could we set up an appointment for her to come see you?

·  HELPER: Yes, I would be glad to see her. Would Monday morning at 11:00 o’clock be okay?

·  BETHANY: (Checks with Anna, who nods) Yes, that would be fine. Her name is Anna Rodriguez. She will see you at 11:00 o’clock Monday. Thank you.

·  Bethany used several strategies to ensure that Anna’s referral was a successful one.

· 1. Discuss with the client the services that are provided by the resource. The discussion should include why the referral is needed, how it will be helpful, how the client feels about it, and what information should be provided. If client information will be shared, then a release form is signed by either the client or guardian at this time.

· 2. Make the referral. This may entail just providing the client with a telephone number and an address or helping him or her with the initial contact, as Bethany did, or it may include taking the initiative to contact the resource. The interaction may involve scheduling an appointment, telling what the client knows about the resource, and/or finding out what information the resource needs. Of course, before any information is released, the client’s permission must be obtained.

Suppose that the referral did not go as planned. When Bethany made the call, Carol Fong might have responded differently—perhaps she couldn’t possibly see Anna until next month, or her agency didn’t do that kind of counseling anymore. Bethany would have two options. She could return to her file to locate another agency that provides the services Anna needs. However, suppose further that this is taking place in a small town or a rural area where there aren’t any other agencies to call. Bethany’s second option would be to become a mobilizer—one who works with other community members to get new resources for clients and communities. Bethany could try to mobilize Carol Fong and other professionals so that needed services could be made available to Anna.

· 3. Share the referral information with the client. He or she needs to know the appointment time, the location, and the name of the person to see upon arrival. It is also appropriate to find out what support the client might need to follow through with the appointment.

· 4. Follow up on the referral. The helper can do this by talking with the client and the helper who received the referral. Did the client show up? What happened? Was the client satisfied with the services? With the worker? Helping professionals with thorough information and referral systems make a habit of noting such information in their files. Information from the worker who saw the client may be conveyed in a phone call, a written report, or not at all.

Bethany followed up on Anna’s referral by talking with her about it the next time they met. She discovered that Anna had had no trouble finding the agency, liked the worker immediately, and felt positive about exploring her options with her. Bethany received no official report from the other agency and did not request one.

The referral process is a flexible one that can be adapted for use with any client, but client participation is vital to good service coordination. Clients participate in the decision to refer and where to refer. Their capabilities determine the extent of their involvement in the steps of the referral process—making an appointment, getting to the agency, and so forth.

The helper’s role in the referral process varies from little involvement to integral involvement, depending on the client’s capabilities. Responsibilities include knowing what resources are available for the client, how to make a referral, and how to assess the client’s capabilities accurately. His or her involvement does not end after the referral; the next step, monitoring services, is also the helper’s responsibility.

Monitoring Services

Once the referral is made, monitoring service delivery becomes the focus of the helping process. Monitoring services is more than following up on the contact; it may mean offering information, intervening in a crisis, or making another referral. The helper continues to act as a broker and a mobilizer throughout this phase of implementation. In  monitoring services , the helper reviews the services received by the client, any conditions that may have changed since the planning phase, and the extent of progress toward the goals and objectives stated in the plan. This review can occur as often as once a day or three times a week or as little as once a month or once a year, depending upon the goals of the program, caseload of the helper, and resources available. One helper in Dearborn, Michigan, who works with clients with mental health issues described the review she conducts in the following way: “The therapist will reevaluate the whole [case] and she would determine what area that person needs or area that she can really help him or somebody else that can help him. So we are really negotiating other services to the best of our ability for the client.”

Review of Services

Once a referral has occurred, delivering the needed service becomes the responsibility of the resource—the agency or professional that has accepted the referral. The helper, however, does not relinquish the case completely. He or she remains in contact with the client to ensure that the services are being delivered, that the client is satisfied with them, and that the agreed-upon time frame is maintained. As you remember, all these are specified in the plan of services.

·  When checking with Rachel Vasquez after her visit to the health clinic, the helper heard about the generous time a volunteer had spent with Rachel in making out a balanced nutrition plan for her son with diabetes. Rachel was excited about knowing what to buy, how to prepare it, and why it made for a good meal. Most of all, she was impressed by how much time the volunteer spent with her.

If there are problems with service delivery, the helper has ultimate responsibility to intervene. Problems may be caused by the agency, the client, or both. For example, the agency may prove unable to see the client for several weeks, or may neglect to do what the client has been promised. The client, on the other hand, may fail to show up for appointments or refuse to cooperate (e.g., be reluctant to give needed information). The helper must be aware of the situation if he or she is to know that intervention is required. The intervention in such a case involves identifying exactly what the problem is and working with the client and the resource to resolve it.

·  Sam Miller received a call from the VA hospital where 22-year-old Raymond Fields (who was mentally challenged) had been placed as an orderly just two weeks before. Both the supervisor and Raymond had been pleased with the match. This morning, the supervisor reported that twice in the past three days, Raymond had been seen unzipping his pants and playing with his penis in the hallways. Sam hastened over to talk with Raymond about the behavior. He told Raymond to keep his pants zipped. There was no more trouble afterwards.

Changing Conditions

Often there is a time lag between plan development and the provision of services. During this period, the helper seeks agency approval, if necessary, and arranges for services either within the agency or at another. It is also likely that there will be changes in the client’s situation during this time. Living arrangements, relationships, income, and emotions are some of the factors that may change. Also the presenting problem may show some alteration, or additional problems may surface. Any such changes may necessitate review and revision of the plan.

·  Alma Justus is raising two granddaughters and one grandson with the help of her own son, Zack. The mother of the children, Alma’s daughter, lives in another state with her boyfriend and his two kids. Alma and the children are receiving assistance from a case manager at the local Office on Aging. Last week Alma was placed in the hospital, and after extensive testing, it was diagnosed that she had had a series of slight strokes. The case manager will work with the family to determine the changing need for services.

The client’s circumstances may also change during service delivery. Part of service monitoring is keeping informed of changes that occur in the client’s life. Some changes may occur as a result of service delivery; for example, a client might learn more appropriate ways to express anger than hitting his spouse. Other changes may have nothing to do with service delivery yet influence it. For example, a client might decide to marry while halfway through service delivery, an action that could well affect her economic eligibility for services. Again, monitoring of services keeps the helper abreast of activities and ready to intervene if necessary.

Evaluating Progress

Monitoring services also entails continually checking progress toward the goals and objectives set forth in the plan of services. Continual evaluation may lead to modification of the plan so as to improve effectiveness or deal with new developments. In monitoring services, the helper repeatedly asks the following questions:

Has the identified problem changed?

Was the referral made correctly?

Were the desired outcomes achieved?

Should the plan be altered?

Should the case be closed?

Monitoring services goes most smoothly if close contact with the client is maintained. Outcome measures focus on the client, so he or she is a key source of information about service delivery. Did the client use the resource? Was the goal of the referral attained? The helper’s responsibility continues until the client’s problem is resolved. Follow-up and monitoring are performed to make sure that referrals result in the desired outcomes.

The following case focuses on how a helper monitors services by reviewing the services received, considering any changes in conditions, and evaluating progress toward goals and objectives.

·  Kim Sue’s father has been incarcerated for four years. Kim, aged six, can only remember seeing his father three times. Twice he visited him in prison, once his father came home for the weekend. Kim’s mother has filed for divorce and wants nothing to do with Kim’s father. Through a lawyer, Kim’s father has communicated with his mother that he is asking for shared custody of their son. Kim’s father will be released from prison in four weeks. He has secured a job with benefits with a local construction company, located housing, and has a record of “good behavior” while in prison.

·  Kim attends a local elementary school. As a first grader, he has been assigned a special helper to meet his emotional needs. He has been diagnosed with attention deficit/hyperactivity disorder (ADHD) and depression. A physician, working with the Department of Human Services, prescribed dextroamphetamine for the ADHD. Kim has a social worker from the Department of Human Services who visits his mother regularly. His mother has been arrested, but not charged, with prostitution and is, reportedly, a methamphetamine user. Kim also sees a helper provided by the Boys and Girls Club once a week.

·  Kim’s teacher, Ms. Knowling, is concerned about him. Kim cycles between being withdrawn and hyperactive. He rarely talks in class most days. Other days he cannot sit still, but he still does not communicate. He maintains a sad face and sometimes puts his head on his desk and cries. The other children don’t know how to relate to him. Sometimes Kim stays in with Ms. Knowling when the rest of the class goes to recess. Kim will talk with Ms. Knowling then. Ms. Knowling has heard over time about Kim’s help from the Department of Human Services, the Boys and Girls Club, his doctor, the school social worker, and the special helper at school. She believes that someone should be responsible for Kim’s case and should have the whole picture concerning his life and the services he is receiving.

In this scenario, there is no service coordinator and no one to monitor the services Kim is receiving. As a result, there is no holistic assessment, planning, and professional helper or agency responsible for his care. If there were service coordination, issues could be outlined, referrals made, and service delivery monitored, all to support the care of Kim.

CHAPTER SUMMARY

At times it is the helper’s responsibility to coordinate services for the client. This means locating resources, making arrangements for clients to use them, and monitoring client use and progress. The helper and the client agree on a plan of service first and then determine what services can be provided by the helper and what services need to be referred. During the resource selection it is important for the client to participate so that the client’s values and preferences and unique circumstances are considered.

Since the helper is working closely with other professionals, there are guidelines that can facilitate working with others on this assessment. Helping professionals are encouraged to use good communication skills, to know their own limits and the limits of other helpers and other agencies, to listen well, and to encourage dialogue about issues of disagreement. Referral and monitoring among helping professionals, at its best, occurs in an atmosphere of understanding and mutual trust.

Because the helper often does not provide all of the services needed, referral is an important component of service coordination. Effective referrals take into account matching the services available with client needs. Readiness of the client to be referred, appropriateness of the referral, and readiness of the new agency to receive the client are all important factors in making a successful referral.

Once a referral is made, it is the helper’s responsibility to monitor the services provided and client progress. This includes a periodic review of the services, a note of changing conditions either on the part of the client or the services being provided, and an evaluation of client progress. Evaluation of the client’s progress is an ongoing responsibility and includes investigating the status of the problems, the satisfaction of the client with the referring agency and staff, the status of the outcomes, and determination of continuation or closure of the case.

CHAPTER REVIEW

Implementing a plan for service delivery often involves the coordination of services by other staff, other agencies, or both. The following list of key terms and review questions will help you affirm the knowledge you gained in studying this chapter.

KEY TERMS

Broker

Coordinating services

Mobilizer

Monitoring services

Referral

Resource selection

REVIEWING THE CHAPTER

1.

Name the three activities of service coordination.

2.

What are the benefits of service coordination?

3.

How would you use a systematic resource selection process when making a referral?

4.

Under what circumstances does a helping professional refer a client?

5.

Discuss three reasons why referrals fail.

6.

What are the steps to a successful referral?

7.

Describe how the roles of broker and mobilizer apply to the monitoring of services.

8.

What are the three components of monitoring services?

QUESTIONS FOR DISCUSSION

1.

Write a short case study that describes a client for whom service coordination would be appropriate.

2.

Describe how the concepts client strengths and client empowerment relate to service coordination.

3.

List the challenges of monitoring services and discuss how you, as a helper, would meet each challenge.

CHAPTER ELEVEN Providing Services

·  Treatment for those with mental illness varies depending on the individual and the diagnosis. Those who have been victims of torture require a different approach than those with schizophrenia or depression.

·  —Mental Health Professional, Dearborn, MI

The implementation phase of the helping process focuses on both providing services to clients and coordinating services when clients require referral and are involved in receiving services from other professionals. Whether coordinating or providing services, implementation follows planning and is based on the goals and objectives established by the helper and the client. This chapter focuses on service provision by the helper and describes the knowledge and skills that are necessary for services such as counseling, advocacy, or education. How helpers address client needs during a crisis situation is also a focus of the chapter. Review the place of providing services in the helping process shown in  Figure 11.1 .

Particularly challenging during the implementation phase is what one helper calls “staying in your lane.” There are important potential ethical dilemmas when you work with people. Often, however, they don’t arise if helping professionals just “stay in their lane” by maintaining boundaries, respecting client self-determination, and acting in accordance with their codes of ethics. Keep this in mind as you read the chapter. After reading this chapter, you should be able to accomplish the following objectives:

Service Provision

· ■ Identify four direct service roles

· ■ Apply each of these roles to client situations

· ■ Evaluate the effectiveness of direct services

Termination

· ■ Know the different ways termination occurs

· ■ Recognize when to end the helping relationship

· ■ Use helping skills to make termination a positive experience

Service Provision

The service plan developed by the helper and the client indicates the goals and objectives that can best be provided directly by the helper. The delivery of services builds on the partnership that has been established in the earlier phases of the helping process. During the assessment and planning phases of the helping process, the helping professional and the client work together to identify areas for which the client wants or needs assistance and develops a plan to address those problems or needs.

Implementation continues that partnership and, in many cases, strengthens it so that the level of trust and rapport is sufficient for the client and the helper to work together on issues and concerns at a deeper level. In the quote that begins this chapter, a therapist in Dearborn, Michigan, who works with victims of torture, explains the approach the agency uses to address mental health issues. Helping, at times, requires therapeutic care around serious mental health issues as well as challenges encountered in everyday living.

Figure 11.1 The Helping Process

There are probably as many different problems as there are clients who benefit from direct services provided by helping professionals, including counselors, human service professionals, social workers, probation and parole officers, and psychologists. Regardless of their professional identity, helping professionals may find themselves acting in the roles of behavior changer, caregiver, teacher, or crisis intervener, among others. Sometimes, the helping professional may engage in one of these roles and at other times, a combination of roles. The following section will introduce four roles that are common in human services and counseling.

Behavior Changer

Often clients experience difficulties because of their behaviors. A helping professional, working with TANF (Temporary Assistance for Needy Families) clients in a rural county in Tennessee, talked about his role in helping teach parents new behaviors: “In their [the clients] personal responsibility plan, they have agreed to keep their children in school, get their shots, and have health check ups.” He is focused on specific behaviors his clients have to demonstrate. He also stated that the agency provides “support services for them” and identifies what they need to change their behaviors. Other issues such as aggression, overeating, uncontrollable anger, passivity, interpersonal difficulties, and habits such as smoking, lying, gambling, and cheating are example of problem behaviors that can cause difficulties for people.

·  Jim has joined a smoking cessation group to stop smoking. He knows it is habit he needs to break, and his wife constantly reminds him that his smoking is an addiction. Her reminders often lead to hurtful words between them and feelings of increased pressure on his part to quit. In fact, all this leads him to smoke even more, and he is sneaking smokes to avoid any more confrontations with her.

Often, clients may know that a behavior is problematic but not know how to change it. Sometimes even recognizing the need to change a behavior creates more anxiety. Jim actually finds himself going in circles with his smoking. He knows it is a problem and wants to quit but the nagging creates pressure that in turn is relieved by smoking. In fact, he may believe he won’t be able to quit, he really doesn’t want to quit, and his two closest friends still smoke and he knows they will sabotage any effort he makes to quit. So this is a much more complex problem than one might initially suspect.

·  Suzanne is devastated at her own behavior. She has three children under the age of five. Her husband works at night and sleeps during the day. He becomes very angry when he can’t sleep because of the noise in the house. The children are too loud, the vacuum cleaner makes too much noise, the phone rings, or the repairman arrives. Yesterday she yelled at all three children and smacked the four-year-old across the face. She was so appalled at her behavior that she sat down and cried.

Suzanne knows she needs to make some changes and she wants to but she’s so overwhelmed she has no idea where to start. It appears she is without allies or support.

Changing behaviors is often difficult and requires the direction, encouragement, and support of a helping professional in the role of  behavior changer . And of course, it’s much easier to change behavior when working with a motivated client, as both Suzanne and Jim will be.

There are many behavior change strategies that are effective. One view of the change process, articulated by Prochaska, Norcross, and DiClemente ( 2006 ), suggests six phases individuals experience as they work through the change process: precontemplation (resisting change); contemplation (change on the horizon); preparation (getting ready); action (time to move); maintenance (staying there); and  termination . As helpers work with the client through the change process, they rely on multiple theories and strategies appropriate for each phase. The following case study focuses on Suzanne and her difficulties. Describing the first four phases and illustrating the strategies that the helper uses to support Suzanne and her change efforts follows.

PRECONTEMPLATION

In this phase of change, individuals do not want to change and resist thinking that there is a problem. They may not feel confident that they can change and may be overwhelmed. Sometimes they intellectualize why they cannot change, believe that the problem resides with others, or ignore any negative feelings they experience.

How can the helper address clients in the precontemplation phase? A first step is to provide information about the problem that exists and identify what clients do to resist change. Then, clients need to find a way to change resistant behaviors into supportive behaviors. A second step is to discover who can help or assist the change process. This means defining the characteristics of a good helper and finding formal and informal helpers to support the change process. Let’s look at Suzanne in this stage of precontemplation.

·  Suzanne’s tears expressed her frustration and regret. She does not know how she could have struck her child. This is not the first time that she has lost her temper and taken her frustration out on her children. She is becoming the mother she swore she would never be; she is becoming her own mother. For months she was sure that she could handle her frustration, and she has told her friends and family that all is well. Yesterday she saw a program on TV about mothering and how to cope with the stresses of raising young children. Today, she finally admitted she needed help, so she talked to her husband. He shut the door in her face and told her not to bother him. She knows she needs to find someone to support her.

CONTEMPLATION

In the second phase of change, individuals acknowledge there is a problem and recognize that change is important. It is accompanied by a fear of change, the unknown, and of failure. Individuals might get stuck in the contemplation stage if they need a guarantee that their efforts will bring success, if they both want things to remain the same and they want them to change, or if they start the action phase of change without preparing for the action. Strategies within the contemplation phase include developing the emotional energy for change, identifying goals, and deciding how change might influence self and others.

·  Suzanne decided she needed formal support. Her best friend had used the services of a family clinic in her neighborhood. She made an appointment and met the helper for the first time. During the first two visits, the helper listened to her story, asked her lots of questions about her life and the lives of her kids, and gave her some videos to watch and material to read about parenting. They also talked about why she wanted to change and in what ways she wanted to change. At the end of the second session, she and the helper talked about how her own life and the lives of her children and her husband could be different.

PREPARATION

In this phase, the client gets ready to change. Many clients want to jump into the change process before they complete a preparation stage. Premature action is one cause of failure to change. During preparation clients can make change a priority and strengthen their commitment to change by acknowledging the anxiety around the change process. Outlining change in small and manageable steps, developing a plan of action, setting a date to begin the change process, and letting others know of the commitment to change alleviate this anxiety. Helping relationships are key during this stage. Helpers support the planning and provide emotional support to counter the anxiety associated with change.

·  During the third session Suzanne and the helper made a specific plan that addressed her taking out her frustration on her children. The goal was to respond in an intentional manner to her children during the afternoon from 2:00 P.M. until 3:00 P.M. the first day and to expand the time by 30 minutes a day until she maintained three hours of intentional responses. This was the time of day that Suzanne had the most trouble keeping her anger and frustration in check. She had role-played her new behaviors with the helper. She made 3” by 5” cards with possible intentional responses. She created a place in the playroom where she could go and do breathing exercises. She also planned check-in phone calls with the helper and bought a small notebook to keep notes of the afternoon responses. And Suzanne moved the playroom to the kitchen, the room farthest away from where her husband slept during the day.

ACTION

This is the phase in which the actual change occurs. The action phase becomes difficult if clients believe that change will be easy, a “magic” answer to the problem exists, or no serious preparation is necessary. Action is more likely to be effective if the client can replace a problem behavior for another behavior. Another strategy is assessing the environment and creating an environment that supports the change process. The third strategy is providing a reward for successful change.

·  Suzanne called the helper at 1:45 P.M. the day she was to use intentional responses. The playroom was moved to the kitchen and Suzanne had rehearsed her interaction with the children. She took 30 seconds for breathing exercises before and after the phone call. She also called her friend who had provided the referral as a measure of support. She made it through the first hour! It was not easy. She took two minutes to write down what had happened, where she felt really successful, and where she was frustrated. Her friend arrived at exactly 3:00 P.M. and they had tea together while the children continued to play. Then they all had cookies and ice cream together.

As you read about the first four phases of Prochaska, Norcross, and DiClemente’s ( 2006 ) process of change, you followed Suzanne’s experience of change within the helping process. The helper performs the role of behavior changer. Two other roles, that of caregiver and teacher, are important to this process of supporting client change.

Caregiver

Helping professionals may also assume the role of  caregiver . In this role, they offer ongoing support of some kind that reflects “a genuine concern for and interest in others and their well-being” (Gladding, 2001 , p. 20). A key to providing care to the client is expressing unconditional positive regard and empathy (Rogers,  1980 ). One way to develop unconditional positive regard is to view all individuals in a positive light and to assume their behavior centers around making a better life for themselves and those around them (Cochran & Cochran,  2006 ). This means that the helper finds the positive motivation for each individual client. Rogers indicated that equally as important as seeing each client in a positive light is developing and communicating empathy. Empathy is “the helper’s ability to see, be aware of, conceptualize, understand, and effectively communicate back to a client the client’s feelings, thoughts, and frame of reference in regard to a situation or point of view” (Gladding,  2001 , p. 50). When we respond in an empathetic way to clients, we mirror who they are, or at least the way we experience them. For some, this indicates we understand them and accept them for who they are, increasing their trust in us and in the helping relationship. A helper working in a Brooklyn shelter stated, “I think the biggest challenge for me is to see each individual client from a fresh start. Not using past experiences such as when I’ve met someone last month who reminds me of the client. Taking each person as an individual and giving them the benefit of the doubt.” Relationships are important and this helper indicates how careful she must be to treat each client with care and attention.

Caregiving occurs throughout the helping process in three ways: building the relationship, being with the client, and doing for the client. Relationship building and tending occurs throughout the helping process; it includes attitudes and responses that indicate unconditional positive regard and empathy. Skills introduced in  Chapter Four  such as listening, attending, questioning, responding, and demonstrating respect for client culture, all support caregiving. In addition, an ethical attitude that values acceptance, respect, self-determination, beneficance, and confidentiality all say to the client, “I respect you and your rights” in the helping process.

Sometimes helpers focus on the client by just “being with” them. They are present to them either in person, by phone, or, more recently, by e-mail. Available 24/7, many helpers provide assurances to clients that they can be there for them in a moment’s notice. “Doing for” represents the actions of helping such as assessing, developing a plan, making a referral, counseling, teaching a skill, or coordinating services. The relationship remains key to these types of caregiving services. Caregiving occurs in a variety of settings; for example, day care, residential helper, hospice, and group leader. Below are two examples of caregiving as it occurs within the helping process.

·  In the past year, the students at a local middle school have experienced a number of losses. A favorite school counselor died suddenly, a math and science teacher lost her battle with cancer, and the husband of another teacher was killed in a car accident. The remaining school counselor has identified eight students who would benefit from a grief group with an experienced bereavement counselor. There are also some students who have requested an individual appointment.

These students need help coping with their grief, support for their feelings, and a time and place for the expression of thoughts and feelings.

·  Families receive services from the Memory and Aging Project Satellite (MAPS) of the Washington University Alzheimer’s Disease Research Center. This program was developed to meet the multiple needs of the underserved elderly with cognitive impairments. Many of these clients had no formal diagnosis of dementia. Members of the home-based services interview both clients and caregivers living in and outside of the home. One difficult problem encountered in this program is that often multiple caregivers do not provide the same advice when assessing needs and making recommendations (Edwards, Baum, & Meisel,  1999 ).

Caregiving in this setting includes relationship building, being with, and doing for. In this case, there are individual clients and the family is also the client. The multiple needs of individuals and families and the difficulties and complexities faced by the families mean that relationships are critical to effective helping.

During the helping process with which Suzanne was engaged described earlier in this chapter, the helper’s role included caregiving. Let’s look at Suzanne’s reflections on the support she received. Suzanne also includes some comments about her friend as an informal helper.

·  I told my friend how grateful I was to her for helping me with my frustrations and my ill-treatment of my children. Not only did she understand what I was going through, she recommended that I seek help in the family clinic down the street. What a good decision that turned out to be! It is too late to know if I can really change, but I think I can and my helper thinks that I can. From the first time I saw the helper, I knew that she believed in me. She listened to me talk and asked me questions so she could better understand my situation. She didn’t talk too much, but the way she responded to me, I knew that she understood how frustrated I was. And she was there for me every step of the way; she still is. She gave me some extra help by giving me things to read, helping me think about different ways I could respond to my children, and she helped me make a plan.

Teacher

Within the role of an educator, the helping professional assists clients in developing certain skills to increase their intellectual, emotional, and behavioral options. The client is a complex individual with many intellectual, emotional, and behavioral possibilities. Clients feel better about themselves when helpers treat them as thinking, feeling, and acting human beings. If the helper believes in and promotes change, change will be easier for the client. We believe that the role of  teacher  supports determining the focus of the helping process and related goal setting, helping clients understand the influence of their environments, and teaching new skills.

One function of the helper is to assist clients in developing their ability to assess fundamental needs and focus on them early in the helping process. Within the role of teacher, the professional needs to assess where the client is in terms of basic needs in order to determine what needs to address first. One helpful approach is to address needs using Maslow’s hierarchy of needs (Maslow,  1971 ). Abraham Maslow, a psychologist, described a hierarchy of human needs that includes basic physical needs, safety and security needs, social and belonging needs, self-needs, and self-actualization needs. He stressed that addressing higher-level needs is difficult unless an individual’s basic needs have been met (Maslow,  1971 ). In other words, if a child is hungry or very tired, or an adult is angry or scared, that child or adult will have difficulty focusing on needs related to belonging or self-actualization. As discussed earlier in the chapter, clients are often so overwhelmed by their situations that they do not know how to identify what they need or where to begin to look for help or solutions. A good place to start is with the most basic needs that are often the simplest to solve and give the client satisfaction early in the helping process.

As an educator, the helper also teaches clients to recognize how their physical and interpersonal environments affect them. Clients are responsible for their own thoughts and behavior. Sometimes, however, clients are unable to make changes because their environments do not support such changes. Clients must be taught to determine the influence their environments have on their lives and to assess when and how their environments can be changed. Sometimes, such changes are impossible.

Developing new skills remains an outcome for many clients as they begin to address the challenges and issues they face. Skills that improve social communication include basics such as listening, responding, and clarifying, as well as more complex skills such as group communication, negotiating, and conflict resolution. For example, a helper working with AIDS clients in Atlanta is providing “services that teach individual skills. It could be a lack of ability to communicate with partners, condom negotiation, safer-sex practices. Some people just don’t know how to maintain intimacy within a relationship and remain safe.” Basic vocational and life skills are the focus of many after-care support groups for ex-offenders, deinstitutionalized patients, the homeless, and others. Learning to complete a job application, obtain identification, write checks, and interview are some of the skills that are taught. Coping skills (breathing, meditation, yoga), self-talk (anger management, enhancing self-concept, developing insight about self), and attention to physical health, enhance mental and physical health. Clients may also learn about relationships and relationship building within families, work groups, and social situations.

·  Let’s see how Suzanne’s helper used the role of teacher to enhance the helping process.

·  The first day Suzanne saw her helper, she was in a state of mental and physical exhaustion. When her helper asked her, “Tell me about yourself,” Suzanne could only cry. Finally together they developed a list of concerns. Then the helper outlined a list of needs [Maslow] and they placed each of Suzanne’s concerns next to one of the needs. Suzanne had food for herself and her family and a secure place to live, but Suzanne noted that she lived in fear. She was afraid that she would hurt her children. So Suzanne decided that was where she wanted the first change to occur.

·  At their second meeting, Suzanne and the helper discussed Suzanne’s environment. Together they identified the strengths that Suzanne had, the past successes she had had with change, and the barriers that made it difficult to change. One barrier was a growing distance between Suzanne and her husband; Suzanne thought that he was angry at her most of the time. Suzanne recognized that that relationship was not her first priority. She also planned a strategy of change that did not depend upon his support. She thought he might be neutral about how she treated the children. And the change process they planned occurred at a time he would be asleep in another part of the house.

·  Suzanne was grateful for all that her helper taught her. For instance, she loved reading about good parenting. The books presented information in a simple way. Step-by-step descriptions were accompanied by clear examples. Suzanne and her helper role-played the behaviors and then Suzanne had homework where she continued practicing the behaviors after the children had gone to bed. Suzanne loved all of the supports that she and the helper built in to the learning process, such as the 3” by 5” cards she used as reminders of what to say when the children yelled and screamed.

Crisis Intervener

Crises seem to be a part of all our lives today. Perhaps because “breaking news” on television, text messages, and weather alarms are the norm, there is still anxiety about events that occur both near and far away. In the past year, one community has experienced a church shooting that left three people dead, five suicides in the middle and high schools, and a car hijacking that ended in the torture and death of a young couple. On a national and international scale, hurricanes, tsunamis, terrorist acts, war, and nuclear threats create a different kind of crisis.

The role of  crisis intervener  is a demanding one both emotionally and physically. A caseworker in a rural area says, “We have 24 hours to make contact with the family and 48 hours to make a ‘face-to-face.’ So we are on the road hitting it.” This particular role demands an immediate focus on the needs of another person, family, and/or community who are experiencing a disruption in their lives with which they cannot cope. This intervention is short term, focused, and concrete. One crisis intervention professional shared the following example:

·  This happened a lot—fleeing an abusive husband with three kids, two boys and one girl. One of the boys is 14 or 15, so he’s too old to go to the shelter, because boys can’t be over 12 or 13 at a lot of women’s and children’s shelters. So you have a family that could be placed but you can’t place them because one kid can’t go.

At this moment, the worker is facing several challenges. The most immediate crisis is food and shelter that very night. Unfortunately, shelter rules create an additional crisis, one that both frustrates and tests the resources of the worker.

Knowing and understanding the life cycle of a crisis are necessary for effective crisis intervention. The helper’s role and the skills and guidelines necessary to support those in crisis guide plan development and action that is short term and focused. The next section reviews the phases of a disaster life cycle and provides an example of crisis intervention from the perspective of a first-responder to Hurricane Katrina victims.

LIFECYCLE OF A DISASTER

Several phases characterize the  lifecycle of a disaster  (Roberts & Ashley,  2008 ). It begins with a pre-incidentphase, at times with a warning. If there is a warning, individuals and communities may be able to prepare. The second phase, the impact or the incident itself, is defined by the response or reaction to those immediately affected. Reactions include fight or flight; some individuals may freeze from shock or they may deny what is happening or will happen. From a day to a week after the disaster, therescue/heroic/miracle phase defines the time when the major focus is on coping. There are things to do and survival becomes the primary goal; energy directed to physical action helps people feel empowered. Some individuals respond differently, as shock results in confusion and difficulty in problem solving. During the honeymoon phase or time of community cohesion, individuals unite in a common effort; help and support come from various sectors. There occurs a sense that things will begin to improve.

Several weeks after a disaster there is a disillusionment phase, or a time when people are coming to terms with the event, working through grief. It is difficult to sustain the immediate response, help from others dissipates, and individuals and communities often believe they have been forgotten. Mental health issues emerge during this phase. Finally, during the reconstruction phase, a new beginning, some resolutions begin to emerge as individuals and communities rebuild their lives. They begin to recognize that the change is permanent; they see progress in recovery.

CRISIS INTERVENER ROLE

The crisis intervener role, for the purpose of this text, focuses on the first three phases of a disaster described by Roberts and Ashley ( 2008 ): impact, or the incident itself, rescue/heroic/miracle, and honeymoon phases. There are six actions that occur during these three phases (James,  2008 ): defining the problem, ensuring client safety, providing support, examining alternatives, making plans, and obtaining commitment. One of these actions, ensuring client safety, reflects the nature of intervening in a crisis. The helper assesses the risk to the client, both physically and psychologically, paying attention to the state of the client and the state of the environment. In addition, special attention to the following should be included in treatment or intervention (The National Child Traumatic Stress Network,  2009 ):

· ■ Awareness of the developmental level of the client—speak to the client using language that he or she can understand. For example, young children with limited language abilities require simple words and play to encourage expression.

· ■ Awareness of cultural or religious practices—culture or religion, at times, help determine the way in which individuals experience crises. For instance, some may see the incidents are predetermined by fate or as God’s will. Possible support or interventions may be faith-based and may be helpful when used sensitively.

· ■ Assessment of developmental or mental health issues that existed prior to the incident—these issues influence the reactions to the current trauma. At times, the individual may be more at risk because of these challenges.

· ■ Normalization of reactions—help clients understand that their reactions are a natural response to crisis; indicate that individuals survive trauma with help and support.

· ■ Reprocess the event in a positive way—provide ways for individuals to “restory” their experiences; allow them to create a positive ending to the event.

· ■ Teach coping skills—increase clients’ awareness of their own feelings and thoughts about the crisis. Teach them how to use relaxation, self-talk, exercise, and anger management techniques to increase their abilities to cope. This is also an example of the teacher/educator role.

In addition, critical skills for this role include listening, remaining calm, ensuring safety, activating resources, and arranging placements.

Let’s look at a helper’s work with the Naylor family, whose home was destroyed by fire. Bettyjean Fleming works with the family during the first week after the disaster.

·  It was chilly on February 17th, but the Naylors were happy. It was Presidents’ Day weekend, and they were going to have three days off. Everyone gathered in the den in front of the fireplace. Jennifer, the younger daughter, was wearing a tank top and shorts to be comfortable, since she had just come down with the chicken pox. Johanna, the older daughter, had gone to look for the kitten her grandparents had given her for Christmas. It appeared to be just another quiet evening.

·  Johanna came in the back door about 6:30 P.M. and said, “Mom, there’s a fire in the garage!” Mrs. Naylor looked out the door that led to the garage and saw flames that were at least 10 feet tall. Calmly she said, “Everybody out,” and headed for the front door. All three of them made it out safely. As the Naylors stood watching the fire consume their home, they wondered what they were going to do and where they were going to go. Would they be able to salvage anything at all?

·  The Burn Shelter in their community immediately stepped in to provide the many services that fire victims need. Bettyjean Fleming, a helper at the Burn Shelter, was assigned to provide direct services to the Naylor family. Once notified of the fire, Ms. Fleming went to the site of the fire to help the family with their immediate needs. Comfort, clothing, a meal, transportation to the hospital, and temporary lodging are among the services the shelter provides. Ms. Fleming also provided psychological support. The Naylors were calmed by Ms. Fleming’s presence. She radiated confidence, spoke to them in a quiet manner, and made sure that she talked with each of the members of the family individually. She also talked with the family as a whole. While she was with Jennifer, she gave Jennifer plenty of time and space to talk. She also gave Jennifer time to play; the Shelter had a playroom and several hours the morning after the fire, Jennifer and Ms. Fleming played together. She met with Johanna and listened to her as she talked about her losses.

·  She seemed to understand what each of them was going through and talked with them about what they could expect over the next few days. She also asked about their home life and was curious about their religious orientation. They told her they were Quakers and asked her if she would call several members of their congregation. Ms. Fleming explained that she could be the family specialist for as long as they felt they needed her support.

Evaluation of Direct Services

Evaluating direct services is an ongoing process. Helping professionals do not wait until a service ends to ascertain its effectiveness. Rather, they evaluate services throughout the process. What is working? Are there barriers? Can we make changes in services? Perhaps the more important concern is how we know what is working or not working.

This makes evaluation particularly challenging in the helping arena. In many professions, the results of service delivery are obvious. An individual no longer has a cough or a fever, a pipe or a leak is repaired, or a student graduates. In each of these examples, an observable outcome indicates that a change has occurred. In the helping professions, the observable outcome is not always so obvious or clear. Instead, we rely on other indicators. For example, we monitor progress throughout the process by seeking feedback from a client, a family member, the court, or an employer—with the client’s permission, of course. This feedback directs any adjustments that might be necessary. Being alert to behavior changes is another way we receive feedback. Have interpersonal relations improved? Is a client making healthier food choices? Has the client followed up with homework assignments? Is the client abiding by probation or parole restrictions? Feedback from the client that indicates an increased understanding of behaviors of self or others is another way we assess progress. What has the client learned that has increased self-awareness, led to alternative ways of behaving, or enabled the client to move forward?

Feedback  is critical to answering these questions that in turn, helps us determine if the client is on track or if some other service, action, or direction is necessary. A head residency helper at an emergency shelter in St. Louis, Missouri, has the responsibility of finding children and youth who live on the streets and providing them with temporary shelter. For those under 18, the helper must track down parents or guardians to provide permission to stay in the shelter. One indication of a successful outcome is admission to the shelter. Unfortunately, the helper says, “There is a reason they are not staying with their guardians in the first place,” so they do not always receive permission for children and youth to stay; some head back to the streets. Once they do enter the shelter there is an additional challenge. “We have kids who are coming in off the street from no structure and putting them into a very structured environment … a lot of the kids don’t quite take to that so well at first. They do kind of get used to it … there can be a lot of resistance.”

Another practice that contributes to ongoing evaluation is a continual review of plan goals and objectives. This action keeps service delivery on track and minimizes tendencies to get sidetracked as other issues or concerns arise. Remember though that goals are statements of intent, and as  Chapter Six  points out, assessment is an ongoing process. Plans are living documents and can be revised as needed. Circumstances change, and a client’s intention in seeking help may change. For example, a young woman deaf since birth believed that her hearing would be restored at age 21, so she refused to try any job that she could easily perform with no hearing. Without destroying her beliefs, talking with a helper over time helped her accept her situation now and move forward with realistic career exploration consistent with her strengths and interests. This is a client who began the helping process with a goal that was modified over time.

Termination

Termination signifies the end of the helping process; it is the final step. You may remember from  Chapter One  that the helping process occurs for an agreed-upon purpose, a situation that makes it time-bound. Once the goal has been reached, then the helping process is over. This doesn’t mean, however, that if a client experiences another problem or needs assistance at a later time, that help is not available. It just means that for this particular problem, situation, or need, the goal has been achieved. This, of course, refers to goals that are reached successfully.

The best case scenario for termination is the one just described. The goal or goals have been reached, and both helper and client are both satisfied with the process and the result. Unfortunately, this is not always the case with termination. Before we discuss some termination strategies, it is important to acknowledge the other ways that termination happens, ways that are not so positive. For example, services may be interrupted by either the helper or the client before the objectives have been reached. Perhaps the client moves from the area; the helper is transferred, promoted, or leaves the agency; or the client refuses to return for services. Other boundaries can influence termination. The school year may end or the number of counseling sessions that have been authorized by a managed care organization is over.

Perhaps most frustrating for a helping professional is the client who just “disappears.” For some reason—and this can be the puzzling aspect—that we never know, the client never calls or comes by again. So the helper never knows what has happened to him or her, leaving the case unresolved and the helper wondering what happened or perhaps questioning what he or she said or did that might have led to this outcome.

·  One of our students interning at a day camp for homeless children worked with four siblings who were staying with their mother at a local shelter. They attended each day until the third week when they just didn’t show up on Tuesday morning. A call to the shelter revealed that they had left in the middle of the night; no one knew where they were or why they left.

Terminations such as this one have implications for the helping professional. Wondering, questioning, doubting, and feeling a sense of loss are among the feelings that an unresolved case may cause. Too many of these may actually lead to burnout caused by feelings of inadequacy or incompetency, or beliefs that you aren’t making a difference. It’s important to deal with these feelings by talking with colleagues, seeking consultation, and requesting supervision.

Suppose that you have been working with a client over time and termination is drawing near. What can you do to promote a positive experience with termination for both you and your client? Meier and Davis ( 2008 ) suggest that participants in the helping process should have a shared, tentative understanding at the beginning of the process about when their work together will be over. This understanding is reached more easily when participants spend some time establishing the goals and objectives discussed in Chapters Six and Seven. In essence, this constitutes agreement about when their work together is over. As termination approaches, some helpful strategies include alerting the client to closure, talking about termination ahead of time, reviewing goals and objectives, sharing feelings about both the work and each other, and discussing follow up should help be needed in the future. Providing resources for additional help and opportunities to touch base periodically may also be helpful. Gradually decreasing the frequency of meetings may also be helpful as the client adapts to the cessation of the helping process.

The feelings that arise with termination for both the helper and the client should be recognized. First, it is important to say goodbye. The participants in the helping process have shared parts of themselves and their lives that have created a unique sense of trust and intimacy. This phase of the helping process is a time to reflect on what has been accomplished and to discuss the future. Saying goodbye is as individual as clients. Some clients will want to delay termination, perhaps fearing that they won’t make it without the helper; others will approach the end eagerly, anxious to be on their own. Second, it is necessary to acknowledge the feelings of both the helper and the client. These may include loss, anxiety, sadness, excitement, and denial. Whatever the feelings are, it is important to recognize and share them. One client summed up her experience this way: “If it had not been for the help I received, not financially but emotionally, I would not be where I am today. I am thankful for the people who helped me along my way, for those that struggled with me—not against me. If not for them, I wouldn’t be where I am today, and my daughter would not be doing as well as she is.”

CHAPTER SUMMARY

Implementation of services takes the form of direct service and service coordination; both are key elements of the helping process. Delivering direct service, the helper performs the roles of behavior changer, caregiver, teacher, and crisis intervener. Each of the roles provides help and support to the client. As a behavior changer, the helper focuses on supporting client development of new feelings, thinking, and actions. Caregivers help clients feel accepted, respected, and empowered to change. Within the role as a teacher, the helper assists in goal setting, assessing the self and the environment, and learning new skills. Helping individuals in a crisis is a unique role providing short-term services to meet physical and psychological needs. Termination is a final responsibility of the helper in the helping process. Regardless of how the process ends, the effectiveness of the helping is measured against the goals and objectives established in the planning phase and adjusted during implementation.

CHAPTER REVIEW

Implementing a plan for service delivery often involves the provision of direct services. To support your review of this chapter, a review of the key terms and attention to the questions can help you affirm your understanding of the provision of services.

KEY TERMS

Behavior changer

Caregiver

Crisis intervener

Feedback

Lifecycle of a disaster

Teacher

Termination

REVIEWING THE CHAPTER

1.

Define four direct service roles.

2.

What are the responsibilities of a behavior changer?

3.

What are the responsibilities of a caregiver?

4.

What are the responsibilities of a teacher?

5.

What are the responsibilities of a crisis intervener?

6.

What are the reasons for evaluating direct services provided?

7.

What are the ways termination of the helping process occurs?

QUESTIONS FOR DISCUSSION

1.

After reading this chapter, how would you decide what roles were needed when providing direct service to clients?

2.

How are the direct service roles (behavior changer, caregiver, teacher, and crisis intervener) related to each other?

3.

After reading this chapter, what evidence can you give that coordinating services is a critical component of the helping process?

4.

How would you know if your implementation was effective? Successful?

5.

What is the role of the helper during the termination of services?

REFERENCES

Cochran, J. F., & Cochran, N. H. (2006). The heart of counseling: A guide to developing therapeutic relationships. Pacific Grove, CA: Brooks Cole.

Edwards, D. F., Baum, C. M., & Meisel, M. (1999). Home-based multidisciplinary diagnosis and treatment of inner-city elderly with dementia. The Gerontologist, 39 (4), 483–8.

Upper Saddle River, NJ: Merrill/Prentice Hall.

Gladding, S. T. (2001). The counseling dictionary: Concise definition of frequently used terms.

James, R. K. (2008). Crisis intervention strategies (6th ed.). Pacific Grove, CA: Brooks Cole.

Maslow, A. (1971). The farther reaches of human nature. New York: Viking.

Brooks Cole/Cengage.

Meier, S. T., & Davis, S. R. (2008). The elements of counseling (6th ed.). Pacific Grove, CA:

Collins.

Prochaska, J. O., Norcorss, J. C., & DiClemente, C. C. (2006). Changing for good. New York:

Roberts, S. B., & Ashley, W. W. C. (2008). Disaster spiritual care: Practical clergy responses to community, regional, and national tragedy. Woodstock, VT: Skylight Paths.

Rogers, C. R. (1980). A way of being. Boston: Houghton Mifflin.

The National Child Traumatic Stress Network. (2009). Children needing extra help: Guidelines for mental health providers. Retrieved from http://www.nctsnet.org/nctsn_assets/pdfs/Children_Needing_Extra_Help.pdf

CHAPTER ELEVEN Providing Services

·  Treatment for those with mental illness varies depending on the individual and the diagnosis. Those who have been victims of torture require a different approach than those with schizophrenia or depression.

·  —Mental Health Professional, Dearborn, MI

The implementation phase of the helping process focuses on both providing services to clients and coordinating services when clients require referral and are involved in receiving services from other professionals. Whether coordinating or providing services, implementation follows planning and is based on the goals and objectives established by the helper and the client. This chapter focuses on service provision by the helper and describes the knowledge and skills that are necessary for services such as counseling, advocacy, or education. How helpers address client needs during a crisis situation is also a focus of the chapter. Review the place of providing services in the helping process shown in  Figure 11.1 .

Particularly challenging during the implementation phase is what one helper calls “staying in your lane.” There are important potential ethical dilemmas when you work with people. Often, however, they don’t arise if helping professionals just “stay in their lane” by maintaining boundaries, respecting client self-determination, and acting in accordance with their codes of ethics. Keep this in mind as you read the chapter. After reading this chapter, you should be able to accomplish the following objectives:

Service Provision

· ■ Identify four direct service roles

· ■ Apply each of these roles to client situations

· ■ Evaluate the effectiveness of direct services

Termination

· ■ Know the different ways termination occurs

· ■ Recognize when to end the helping relationship

· ■ Use helping skills to make termination a positive experience

Service Provision

The service plan developed by the helper and the client indicates the goals and objectives that can best be provided directly by the helper. The delivery of services builds on the partnership that has been established in the earlier phases of the helping process. During the assessment and planning phases of the helping process, the helping professional and the client work together to identify areas for which the client wants or needs assistance and develops a plan to address those problems or needs.

Implementation continues that partnership and, in many cases, strengthens it so that the level of trust and rapport is sufficient for the client and the helper to work together on issues and concerns at a deeper level. In the quote that begins this chapter, a therapist in Dearborn, Michigan, who works with victims of torture, explains the approach the agency uses to address mental health issues. Helping, at times, requires therapeutic care around serious mental health issues as well as challenges encountered in everyday living.

Figure 11.1 The Helping Process

There are probably as many different problems as there are clients who benefit from direct services provided by helping professionals, including counselors, human service professionals, social workers, probation and parole officers, and psychologists. Regardless of their professional identity, helping professionals may find themselves acting in the roles of behavior changer, caregiver, teacher, or crisis intervener, among others. Sometimes, the helping professional may engage in one of these roles and at other times, a combination of roles. The following section will introduce four roles that are common in human services and counseling.

Behavior Changer

Often clients experience difficulties because of their behaviors. A helping professional, working with TANF (Temporary Assistance for Needy Families) clients in a rural county in Tennessee, talked about his role in helping teach parents new behaviors: “In their [the clients] personal responsibility plan, they have agreed to keep their children in school, get their shots, and have health check ups.” He is focused on specific behaviors his clients have to demonstrate. He also stated that the agency provides “support services for them” and identifies what they need to change their behaviors. Other issues such as aggression, overeating, uncontrollable anger, passivity, interpersonal difficulties, and habits such as smoking, lying, gambling, and cheating are example of problem behaviors that can cause difficulties for people.

·  Jim has joined a smoking cessation group to stop smoking. He knows it is habit he needs to break, and his wife constantly reminds him that his smoking is an addiction. Her reminders often lead to hurtful words between them and feelings of increased pressure on his part to quit. In fact, all this leads him to smoke even more, and he is sneaking smokes to avoid any more confrontations with her.

Often, clients may know that a behavior is problematic but not know how to change it. Sometimes even recognizing the need to change a behavior creates more anxiety. Jim actually finds himself going in circles with his smoking. He knows it is a problem and wants to quit but the nagging creates pressure that in turn is relieved by smoking. In fact, he may believe he won’t be able to quit, he really doesn’t want to quit, and his two closest friends still smoke and he knows they will sabotage any effort he makes to quit. So this is a much more complex problem than one might initially suspect.

·  Suzanne is devastated at her own behavior. She has three children under the age of five. Her husband works at night and sleeps during the day. He becomes very angry when he can’t sleep because of the noise in the house. The children are too loud, the vacuum cleaner makes too much noise, the phone rings, or the repairman arrives. Yesterday she yelled at all three children and smacked the four-year-old across the face. She was so appalled at her behavior that she sat down and cried.

Suzanne knows she needs to make some changes and she wants to but she’s so overwhelmed she has no idea where to start. It appears she is without allies or support.

Changing behaviors is often difficult and requires the direction, encouragement, and support of a helping professional in the role of  behavior changer . And of course, it’s much easier to change behavior when working with a motivated client, as both Suzanne and Jim will be.

There are many behavior change strategies that are effective. One view of the change process, articulated by Prochaska, Norcross, and DiClemente ( 2006 ), suggests six phases individuals experience as they work through the change process: precontemplation (resisting change); contemplation (change on the horizon); preparation (getting ready); action (time to move); maintenance (staying there); and  termination . As helpers work with the client through the change process, they rely on multiple theories and strategies appropriate for each phase. The following case study focuses on Suzanne and her difficulties. Describing the first four phases and illustrating the strategies that the helper uses to support Suzanne and her change efforts follows.

PRECONTEMPLATION

In this phase of change, individuals do not want to change and resist thinking that there is a problem. They may not feel confident that they can change and may be overwhelmed. Sometimes they intellectualize why they cannot change, believe that the problem resides with others, or ignore any negative feelings they experience.

How can the helper address clients in the precontemplation phase? A first step is to provide information about the problem that exists and identify what clients do to resist change. Then, clients need to find a way to change resistant behaviors into supportive behaviors. A second step is to discover who can help or assist the change process. This means defining the characteristics of a good helper and finding formal and informal helpers to support the change process. Let’s look at Suzanne in this stage of precontemplation.

·  Suzanne’s tears expressed her frustration and regret. She does not know how she could have struck her child. This is not the first time that she has lost her temper and taken her frustration out on her children. She is becoming the mother she swore she would never be; she is becoming her own mother. For months she was sure that she could handle her frustration, and she has told her friends and family that all is well. Yesterday she saw a program on TV about mothering and how to cope with the stresses of raising young children. Today, she finally admitted she needed help, so she talked to her husband. He shut the door in her face and told her not to bother him. She knows she needs to find someone to support her.

CONTEMPLATION

In the second phase of change, individuals acknowledge there is a problem and recognize that change is important. It is accompanied by a fear of change, the unknown, and of failure. Individuals might get stuck in the contemplation stage if they need a guarantee that their efforts will bring success, if they both want things to remain the same and they want them to change, or if they start the action phase of change without preparing for the action. Strategies within the contemplation phase include developing the emotional energy for change, identifying goals, and deciding how change might influence self and others.

·  Suzanne decided she needed formal support. Her best friend had used the services of a family clinic in her neighborhood. She made an appointment and met the helper for the first time. During the first two visits, the helper listened to her story, asked her lots of questions about her life and the lives of her kids, and gave her some videos to watch and material to read about parenting. They also talked about why she wanted to change and in what ways she wanted to change. At the end of the second session, she and the helper talked about how her own life and the lives of her children and her husband could be different.

PREPARATION

In this phase, the client gets ready to change. Many clients want to jump into the change process before they complete a preparation stage. Premature action is one cause of failure to change. During preparation clients can make change a priority and strengthen their commitment to change by acknowledging the anxiety around the change process. Outlining change in small and manageable steps, developing a plan of action, setting a date to begin the change process, and letting others know of the commitment to change alleviate this anxiety. Helping relationships are key during this stage. Helpers support the planning and provide emotional support to counter the anxiety associated with change.

·  During the third session Suzanne and the helper made a specific plan that addressed her taking out her frustration on her children. The goal was to respond in an intentional manner to her children during the afternoon from 2:00 P.M. until 3:00 P.M. the first day and to expand the time by 30 minutes a day until she maintained three hours of intentional responses. This was the time of day that Suzanne had the most trouble keeping her anger and frustration in check. She had role-played her new behaviors with the helper. She made 3” by 5” cards with possible intentional responses. She created a place in the playroom where she could go and do breathing exercises. She also planned check-in phone calls with the helper and bought a small notebook to keep notes of the afternoon responses. And Suzanne moved the playroom to the kitchen, the room farthest away from where her husband slept during the day.

ACTION

This is the phase in which the actual change occurs. The action phase becomes difficult if clients believe that change will be easy, a “magic” answer to the problem exists, or no serious preparation is necessary. Action is more likely to be effective if the client can replace a problem behavior for another behavior. Another strategy is assessing the environment and creating an environment that supports the change process. The third strategy is providing a reward for successful change.

·  Suzanne called the helper at 1:45 P.M. the day she was to use intentional responses. The playroom was moved to the kitchen and Suzanne had rehearsed her interaction with the children. She took 30 seconds for breathing exercises before and after the phone call. She also called her friend who had provided the referral as a measure of support. She made it through the first hour! It was not easy. She took two minutes to write down what had happened, where she felt really successful, and where she was frustrated. Her friend arrived at exactly 3:00 P.M. and they had tea together while the children continued to play. Then they all had cookies and ice cream together.

As you read about the first four phases of Prochaska, Norcross, and DiClemente’s ( 2006 ) process of change, you followed Suzanne’s experience of change within the helping process. The helper performs the role of behavior changer. Two other roles, that of caregiver and teacher, are important to this process of supporting client change.

Caregiver

Helping professionals may also assume the role of  caregiver . In this role, they offer ongoing support of some kind that reflects “a genuine concern for and interest in others and their well-being” (Gladding, 2001 , p. 20). A key to providing care to the client is expressing unconditional positive regard and empathy (Rogers,  1980 ). One way to develop unconditional positive regard is to view all individuals in a positive light and to assume their behavior centers around making a better life for themselves and those around them (Cochran & Cochran,  2006 ). This means that the helper finds the positive motivation for each individual client. Rogers indicated that equally as important as seeing each client in a positive light is developing and communicating empathy. Empathy is “the helper’s ability to see, be aware of, conceptualize, understand, and effectively communicate back to a client the client’s feelings, thoughts, and frame of reference in regard to a situation or point of view” (Gladding,  2001 , p. 50). When we respond in an empathetic way to clients, we mirror who they are, or at least the way we experience them. For some, this indicates we understand them and accept them for who they are, increasing their trust in us and in the helping relationship. A helper working in a Brooklyn shelter stated, “I think the biggest challenge for me is to see each individual client from a fresh start. Not using past experiences such as when I’ve met someone last month who reminds me of the client. Taking each person as an individual and giving them the benefit of the doubt.” Relationships are important and this helper indicates how careful she must be to treat each client with care and attention.

Caregiving occurs throughout the helping process in three ways: building the relationship, being with the client, and doing for the client. Relationship building and tending occurs throughout the helping process; it includes attitudes and responses that indicate unconditional positive regard and empathy. Skills introduced in  Chapter Four  such as listening, attending, questioning, responding, and demonstrating respect for client culture, all support caregiving. In addition, an ethical attitude that values acceptance, respect, self-determination, beneficance, and confidentiality all say to the client, “I respect you and your rights” in the helping process.

Sometimes helpers focus on the client by just “being with” them. They are present to them either in person, by phone, or, more recently, by e-mail. Available 24/7, many helpers provide assurances to clients that they can be there for them in a moment’s notice. “Doing for” represents the actions of helping such as assessing, developing a plan, making a referral, counseling, teaching a skill, or coordinating services. The relationship remains key to these types of caregiving services. Caregiving occurs in a variety of settings; for example, day care, residential helper, hospice, and group leader. Below are two examples of caregiving as it occurs within the helping process.

·  In the past year, the students at a local middle school have experienced a number of losses. A favorite school counselor died suddenly, a math and science teacher lost her battle with cancer, and the husband of another teacher was killed in a car accident. The remaining school counselor has identified eight students who would benefit from a grief group with an experienced bereavement counselor. There are also some students who have requested an individual appointment.

These students need help coping with their grief, support for their feelings, and a time and place for the expression of thoughts and feelings.

·  Families receive services from the Memory and Aging Project Satellite (MAPS) of the Washington University Alzheimer’s Disease Research Center. This program was developed to meet the multiple needs of the underserved elderly with cognitive impairments. Many of these clients had no formal diagnosis of dementia. Members of the home-based services interview both clients and caregivers living in and outside of the home. One difficult problem encountered in this program is that often multiple caregivers do not provide the same advice when assessing needs and making recommendations (Edwards, Baum, & Meisel,  1999 ).

Caregiving in this setting includes relationship building, being with, and doing for. In this case, there are individual clients and the family is also the client. The multiple needs of individuals and families and the difficulties and complexities faced by the families mean that relationships are critical to effective helping.

During the helping process with which Suzanne was engaged described earlier in this chapter, the helper’s role included caregiving. Let’s look at Suzanne’s reflections on the support she received. Suzanne also includes some comments about her friend as an informal helper.

·  I told my friend how grateful I was to her for helping me with my frustrations and my ill-treatment of my children. Not only did she understand what I was going through, she recommended that I seek help in the family clinic down the street. What a good decision that turned out to be! It is too late to know if I can really change, but I think I can and my helper thinks that I can. From the first time I saw the helper, I knew that she believed in me. She listened to me talk and asked me questions so she could better understand my situation. She didn’t talk too much, but the way she responded to me, I knew that she understood how frustrated I was. And she was there for me every step of the way; she still is. She gave me some extra help by giving me things to read, helping me think about different ways I could respond to my children, and she helped me make a plan.

Teacher

Within the role of an educator, the helping professional assists clients in developing certain skills to increase their intellectual, emotional, and behavioral options. The client is a complex individual with many intellectual, emotional, and behavioral possibilities. Clients feel better about themselves when helpers treat them as thinking, feeling, and acting human beings. If the helper believes in and promotes change, change will be easier for the client. We believe that the role of  teacher  supports determining the focus of the helping process and related goal setting, helping clients understand the influence of their environments, and teaching new skills.

One function of the helper is to assist clients in developing their ability to assess fundamental needs and focus on them early in the helping process. Within the role of teacher, the professional needs to assess where the client is in terms of basic needs in order to determine what needs to address first. One helpful approach is to address needs using Maslow’s hierarchy of needs (Maslow,  1971 ). Abraham Maslow, a psychologist, described a hierarchy of human needs that includes basic physical needs, safety and security needs, social and belonging needs, self-needs, and self-actualization needs. He stressed that addressing higher-level needs is difficult unless an individual’s basic needs have been met (Maslow,  1971 ). In other words, if a child is hungry or very tired, or an adult is angry or scared, that child or adult will have difficulty focusing on needs related to belonging or self-actualization. As discussed earlier in the chapter, clients are often so overwhelmed by their situations that they do not know how to identify what they need or where to begin to look for help or solutions. A good place to start is with the most basic needs that are often the simplest to solve and give the client satisfaction early in the helping process.

As an educator, the helper also teaches clients to recognize how their physical and interpersonal environments affect them. Clients are responsible for their own thoughts and behavior. Sometimes, however, clients are unable to make changes because their environments do not support such changes. Clients must be taught to determine the influence their environments have on their lives and to assess when and how their environments can be changed. Sometimes, such changes are impossible.

Developing new skills remains an outcome for many clients as they begin to address the challenges and issues they face. Skills that improve social communication include basics such as listening, responding, and clarifying, as well as more complex skills such as group communication, negotiating, and conflict resolution. For example, a helper working with AIDS clients in Atlanta is providing “services that teach individual skills. It could be a lack of ability to communicate with partners, condom negotiation, safer-sex practices. Some people just don’t know how to maintain intimacy within a relationship and remain safe.” Basic vocational and life skills are the focus of many after-care support groups for ex-offenders, deinstitutionalized patients, the homeless, and others. Learning to complete a job application, obtain identification, write checks, and interview are some of the skills that are taught. Coping skills (breathing, meditation, yoga), self-talk (anger management, enhancing self-concept, developing insight about self), and attention to physical health, enhance mental and physical health. Clients may also learn about relationships and relationship building within families, work groups, and social situations.

·  Let’s see how Suzanne’s helper used the role of teacher to enhance the helping process.

·  The first day Suzanne saw her helper, she was in a state of mental and physical exhaustion. When her helper asked her, “Tell me about yourself,” Suzanne could only cry. Finally together they developed a list of concerns. Then the helper outlined a list of needs [Maslow] and they placed each of Suzanne’s concerns next to one of the needs. Suzanne had food for herself and her family and a secure place to live, but Suzanne noted that she lived in fear. She was afraid that she would hurt her children. So Suzanne decided that was where she wanted the first change to occur.

·  At their second meeting, Suzanne and the helper discussed Suzanne’s environment. Together they identified the strengths that Suzanne had, the past successes she had had with change, and the barriers that made it difficult to change. One barrier was a growing distance between Suzanne and her husband; Suzanne thought that he was angry at her most of the time. Suzanne recognized that that relationship was not her first priority. She also planned a strategy of change that did not depend upon his support. She thought he might be neutral about how she treated the children. And the change process they planned occurred at a time he would be asleep in another part of the house.

·  Suzanne was grateful for all that her helper taught her. For instance, she loved reading about good parenting. The books presented information in a simple way. Step-by-step descriptions were accompanied by clear examples. Suzanne and her helper role-played the behaviors and then Suzanne had homework where she continued practicing the behaviors after the children had gone to bed. Suzanne loved all of the supports that she and the helper built in to the learning process, such as the 3” by 5” cards she used as reminders of what to say when the children yelled and screamed.

Crisis Intervener

Crises seem to be a part of all our lives today. Perhaps because “breaking news” on television, text messages, and weather alarms are the norm, there is still anxiety about events that occur both near and far away. In the past year, one community has experienced a church shooting that left three people dead, five suicides in the middle and high schools, and a car hijacking that ended in the torture and death of a young couple. On a national and international scale, hurricanes, tsunamis, terrorist acts, war, and nuclear threats create a different kind of crisis.

The role of  crisis intervener  is a demanding one both emotionally and physically. A caseworker in a rural area says, “We have 24 hours to make contact with the family and 48 hours to make a ‘face-to-face.’ So we are on the road hitting it.” This particular role demands an immediate focus on the needs of another person, family, and/or community who are experiencing a disruption in their lives with which they cannot cope. This intervention is short term, focused, and concrete. One crisis intervention professional shared the following example:

·  This happened a lot—fleeing an abusive husband with three kids, two boys and one girl. One of the boys is 14 or 15, so he’s too old to go to the shelter, because boys can’t be over 12 or 13 at a lot of women’s and children’s shelters. So you have a family that could be placed but you can’t place them because one kid can’t go.

At this moment, the worker is facing several challenges. The most immediate crisis is food and shelter that very night. Unfortunately, shelter rules create an additional crisis, one that both frustrates and tests the resources of the worker.

Knowing and understanding the life cycle of a crisis are necessary for effective crisis intervention. The helper’s role and the skills and guidelines necessary to support those in crisis guide plan development and action that is short term and focused. The next section reviews the phases of a disaster life cycle and provides an example of crisis intervention from the perspective of a first-responder to Hurricane Katrina victims.

LIFECYCLE OF A DISASTER

Several phases characterize the  lifecycle of a disaster  (Roberts & Ashley,  2008 ). It begins with a pre-incidentphase, at times with a warning. If there is a warning, individuals and communities may be able to prepare. The second phase, the impact or the incident itself, is defined by the response or reaction to those immediately affected. Reactions include fight or flight; some individuals may freeze from shock or they may deny what is happening or will happen. From a day to a week after the disaster, therescue/heroic/miracle phase defines the time when the major focus is on coping. There are things to do and survival becomes the primary goal; energy directed to physical action helps people feel empowered. Some individuals respond differently, as shock results in confusion and difficulty in problem solving. During the honeymoon phase or time of community cohesion, individuals unite in a common effort; help and support come from various sectors. There occurs a sense that things will begin to improve.

Several weeks after a disaster there is a disillusionment phase, or a time when people are coming to terms with the event, working through grief. It is difficult to sustain the immediate response, help from others dissipates, and individuals and communities often believe they have been forgotten. Mental health issues emerge during this phase. Finally, during the reconstruction phase, a new beginning, some resolutions begin to emerge as individuals and communities rebuild their lives. They begin to recognize that the change is permanent; they see progress in recovery.

CRISIS INTERVENER ROLE

The crisis intervener role, for the purpose of this text, focuses on the first three phases of a disaster described by Roberts and Ashley ( 2008 ): impact, or the incident itself, rescue/heroic/miracle, and honeymoon phases. There are six actions that occur during these three phases (James,  2008 ): defining the problem, ensuring client safety, providing support, examining alternatives, making plans, and obtaining commitment. One of these actions, ensuring client safety, reflects the nature of intervening in a crisis. The helper assesses the risk to the client, both physically and psychologically, paying attention to the state of the client and the state of the environment. In addition, special attention to the following should be included in treatment or intervention (The National Child Traumatic Stress Network,  2009 ):

· ■ Awareness of the developmental level of the client—speak to the client using language that he or she can understand. For example, young children with limited language abilities require simple words and play to encourage expression.

· ■ Awareness of cultural or religious practices—culture or religion, at times, help determine the way in which individuals experience crises. For instance, some may see the incidents are predetermined by fate or as God’s will. Possible support or interventions may be faith-based and may be helpful when used sensitively.

· ■ Assessment of developmental or mental health issues that existed prior to the incident—these issues influence the reactions to the current trauma. At times, the individual may be more at risk because of these challenges.

· ■ Normalization of reactions—help clients understand that their reactions are a natural response to crisis; indicate that individuals survive trauma with help and support.

· ■ Reprocess the event in a positive way—provide ways for individuals to “restory” their experiences; allow them to create a positive ending to the event.

· ■ Teach coping skills—increase clients’ awareness of their own feelings and thoughts about the crisis. Teach them how to use relaxation, self-talk, exercise, and anger management techniques to increase their abilities to cope. This is also an example of the teacher/educator role.

In addition, critical skills for this role include listening, remaining calm, ensuring safety, activating resources, and arranging placements.

Let’s look at a helper’s work with the Naylor family, whose home was destroyed by fire. Bettyjean Fleming works with the family during the first week after the disaster.

·  It was chilly on February 17th, but the Naylors were happy. It was Presidents’ Day weekend, and they were going to have three days off. Everyone gathered in the den in front of the fireplace. Jennifer, the younger daughter, was wearing a tank top and shorts to be comfortable, since she had just come down with the chicken pox. Johanna, the older daughter, had gone to look for the kitten her grandparents had given her for Christmas. It appeared to be just another quiet evening.

·  Johanna came in the back door about 6:30 P.M. and said, “Mom, there’s a fire in the garage!” Mrs. Naylor looked out the door that led to the garage and saw flames that were at least 10 feet tall. Calmly she said, “Everybody out,” and headed for the front door. All three of them made it out safely. As the Naylors stood watching the fire consume their home, they wondered what they were going to do and where they were going to go. Would they be able to salvage anything at all?

·  The Burn Shelter in their community immediately stepped in to provide the many services that fire victims need. Bettyjean Fleming, a helper at the Burn Shelter, was assigned to provide direct services to the Naylor family. Once notified of the fire, Ms. Fleming went to the site of the fire to help the family with their immediate needs. Comfort, clothing, a meal, transportation to the hospital, and temporary lodging are among the services the shelter provides. Ms. Fleming also provided psychological support. The Naylors were calmed by Ms. Fleming’s presence. She radiated confidence, spoke to them in a quiet manner, and made sure that she talked with each of the members of the family individually. She also talked with the family as a whole. While she was with Jennifer, she gave Jennifer plenty of time and space to talk. She also gave Jennifer time to play; the Shelter had a playroom and several hours the morning after the fire, Jennifer and Ms. Fleming played together. She met with Johanna and listened to her as she talked about her losses.

·  She seemed to understand what each of them was going through and talked with them about what they could expect over the next few days. She also asked about their home life and was curious about their religious orientation. They told her they were Quakers and asked her if she would call several members of their congregation. Ms. Fleming explained that she could be the family specialist for as long as they felt they needed her support.

Evaluation of Direct Services

Evaluating direct services is an ongoing process. Helping professionals do not wait until a service ends to ascertain its effectiveness. Rather, they evaluate services throughout the process. What is working? Are there barriers? Can we make changes in services? Perhaps the more important concern is how we know what is working or not working.

This makes evaluation particularly challenging in the helping arena. In many professions, the results of service delivery are obvious. An individual no longer has a cough or a fever, a pipe or a leak is repaired, or a student graduates. In each of these examples, an observable outcome indicates that a change has occurred. In the helping professions, the observable outcome is not always so obvious or clear. Instead, we rely on other indicators. For example, we monitor progress throughout the process by seeking feedback from a client, a family member, the court, or an employer—with the client’s permission, of course. This feedback directs any adjustments that might be necessary. Being alert to behavior changes is another way we receive feedback. Have interpersonal relations improved? Is a client making healthier food choices? Has the client followed up with homework assignments? Is the client abiding by probation or parole restrictions? Feedback from the client that indicates an increased understanding of behaviors of self or others is another way we assess progress. What has the client learned that has increased self-awareness, led to alternative ways of behaving, or enabled the client to move forward?

Feedback  is critical to answering these questions that in turn, helps us determine if the client is on track or if some other service, action, or direction is necessary. A head residency helper at an emergency shelter in St. Louis, Missouri, has the responsibility of finding children and youth who live on the streets and providing them with temporary shelter. For those under 18, the helper must track down parents or guardians to provide permission to stay in the shelter. One indication of a successful outcome is admission to the shelter. Unfortunately, the helper says, “There is a reason they are not staying with their guardians in the first place,” so they do not always receive permission for children and youth to stay; some head back to the streets. Once they do enter the shelter there is an additional challenge. “We have kids who are coming in off the street from no structure and putting them into a very structured environment … a lot of the kids don’t quite take to that so well at first. They do kind of get used to it … there can be a lot of resistance.”

Another practice that contributes to ongoing evaluation is a continual review of plan goals and objectives. This action keeps service delivery on track and minimizes tendencies to get sidetracked as other issues or concerns arise. Remember though that goals are statements of intent, and as  Chapter Six  points out, assessment is an ongoing process. Plans are living documents and can be revised as needed. Circumstances change, and a client’s intention in seeking help may change. For example, a young woman deaf since birth believed that her hearing would be restored at age 21, so she refused to try any job that she could easily perform with no hearing. Without destroying her beliefs, talking with a helper over time helped her accept her situation now and move forward with realistic career exploration consistent with her strengths and interests. This is a client who began the helping process with a goal that was modified over time.

Termination

Termination signifies the end of the helping process; it is the final step. You may remember from  Chapter One  that the helping process occurs for an agreed-upon purpose, a situation that makes it time-bound. Once the goal has been reached, then the helping process is over. This doesn’t mean, however, that if a client experiences another problem or needs assistance at a later time, that help is not available. It just means that for this particular problem, situation, or need, the goal has been achieved. This, of course, refers to goals that are reached successfully.

The best case scenario for termination is the one just described. The goal or goals have been reached, and both helper and client are both satisfied with the process and the result. Unfortunately, this is not always the case with termination. Before we discuss some termination strategies, it is important to acknowledge the other ways that termination happens, ways that are not so positive. For example, services may be interrupted by either the helper or the client before the objectives have been reached. Perhaps the client moves from the area; the helper is transferred, promoted, or leaves the agency; or the client refuses to return for services. Other boundaries can influence termination. The school year may end or the number of counseling sessions that have been authorized by a managed care organization is over.

Perhaps most frustrating for a helping professional is the client who just “disappears.” For some reason—and this can be the puzzling aspect—that we never know, the client never calls or comes by again. So the helper never knows what has happened to him or her, leaving the case unresolved and the helper wondering what happened or perhaps questioning what he or she said or did that might have led to this outcome.

·  One of our students interning at a day camp for homeless children worked with four siblings who were staying with their mother at a local shelter. They attended each day until the third week when they just didn’t show up on Tuesday morning. A call to the shelter revealed that they had left in the middle of the night; no one knew where they were or why they left.

Terminations such as this one have implications for the helping professional. Wondering, questioning, doubting, and feeling a sense of loss are among the feelings that an unresolved case may cause. Too many of these may actually lead to burnout caused by feelings of inadequacy or incompetency, or beliefs that you aren’t making a difference. It’s important to deal with these feelings by talking with colleagues, seeking consultation, and requesting supervision.

Suppose that you have been working with a client over time and termination is drawing near. What can you do to promote a positive experience with termination for both you and your client? Meier and Davis ( 2008 ) suggest that participants in the helping process should have a shared, tentative understanding at the beginning of the process about when their work together will be over. This understanding is reached more easily when participants spend some time establishing the goals and objectives discussed in Chapters Six and Seven. In essence, this constitutes agreement about when their work together is over. As termination approaches, some helpful strategies include alerting the client to closure, talking about termination ahead of time, reviewing goals and objectives, sharing feelings about both the work and each other, and discussing follow up should help be needed in the future. Providing resources for additional help and opportunities to touch base periodically may also be helpful. Gradually decreasing the frequency of meetings may also be helpful as the client adapts to the cessation of the helping process.

The feelings that arise with termination for both the helper and the client should be recognized. First, it is important to say goodbye. The participants in the helping process have shared parts of themselves and their lives that have created a unique sense of trust and intimacy. This phase of the helping process is a time to reflect on what has been accomplished and to discuss the future. Saying goodbye is as individual as clients. Some clients will want to delay termination, perhaps fearing that they won’t make it without the helper; others will approach the end eagerly, anxious to be on their own. Second, it is necessary to acknowledge the feelings of both the helper and the client. These may include loss, anxiety, sadness, excitement, and denial. Whatever the feelings are, it is important to recognize and share them. One client summed up her experience this way: “If it had not been for the help I received, not financially but emotionally, I would not be where I am today. I am thankful for the people who helped me along my way, for those that struggled with me—not against me. If not for them, I wouldn’t be where I am today, and my daughter would not be doing as well as she is.”

CHAPTER SUMMARY

Implementation of services takes the form of direct service and service coordination; both are key elements of the helping process. Delivering direct service, the helper performs the roles of behavior changer, caregiver, teacher, and crisis intervener. Each of the roles provides help and support to the client. As a behavior changer, the helper focuses on supporting client development of new feelings, thinking, and actions. Caregivers help clients feel accepted, respected, and empowered to change. Within the role as a teacher, the helper assists in goal setting, assessing the self and the environment, and learning new skills. Helping individuals in a crisis is a unique role providing short-term services to meet physical and psychological needs. Termination is a final responsibility of the helper in the helping process. Regardless of how the process ends, the effectiveness of the helping is measured against the goals and objectives established in the planning phase and adjusted during implementation.

CHAPTER REVIEW

Implementing a plan for service delivery often involves the provision of direct services. To support your review of this chapter, a review of the key terms and attention to the questions can help you affirm your understanding of the provision of services.

KEY TERMS

Behavior changer

Caregiver

Crisis intervener

Feedback

Lifecycle of a disaster

Teacher

Termination

REVIEWING THE CHAPTER

1.

Define four direct service roles.

2.

What are the responsibilities of a behavior changer?

3.

What are the responsibilities of a caregiver?

4.

What are the responsibilities of a teacher?

5.

What are the responsibilities of a crisis intervener?

6.

What are the reasons for evaluating direct services provided?

7.

What are the ways termination of the helping process occurs?

QUESTIONS FOR DISCUSSION

1.

After reading this chapter, how would you decide what roles were needed when providing direct service to clients?

2.

How are the direct service roles (behavior changer, caregiver, teacher, and crisis intervener) related to each other?

3.

After reading this chapter, what evidence can you give that coordinating services is a critical component of the helping process?

4.

How would you know if your implementation was effective? Successful?

5.

What is the role of the helper during the termination of services?

REFERENCES

Cochran, J. F., & Cochran, N. H. (2006). The heart of counseling: A guide to developing therapeutic relationships. Pacific Grove, CA: Brooks Cole.

Edwards, D. F., Baum, C. M., & Meisel, M. (1999). Home-based multidisciplinary diagnosis and treatment of inner-city elderly with dementia. The Gerontologist, 39 (4), 483–8.

Upper Saddle River, NJ: Merrill/Prentice Hall.

Gladding, S. T. (2001). The counseling dictionary: Concise definition of frequently used terms.

James, R. K. (2008). Crisis intervention strategies (6th ed.). Pacific Grove, CA: Brooks Cole.

Maslow, A. (1971). The farther reaches of human nature. New York: Viking.

Brooks Cole/Cengage.

Meier, S. T., & Davis, S. R. (2008). The elements of counseling (6th ed.). Pacific Grove, CA:

Collins.

Prochaska, J. O., Norcorss, J. C., & DiClemente, C. C. (2006). Changing for good. New York:

Roberts, S. B., & Ashley, W. W. C. (2008). Disaster spiritual care: Practical clergy responses to community, regional, and national tragedy. Woodstock, VT: Skylight Paths.

Rogers, C. R. (1980). A way of being. Boston: Houghton Mifflin.

The National Child Traumatic Stress Network. (2009). Children needing extra help: Guidelines for mental health providers. Retrieved from http://www.nctsnet.org/nctsn_assets/pdfs/Children_Needing_Extra_Help.pdf