CHAPTER ONE Introducing the Helping Process

·  I work at an agency that serves adolescent females. The length of stay at our short-term facility varies from 14 to 30 days, depending on their situation. We have kids who are in state custody and need temporary housing, juvenile court placements, homeless, or in crisis. Individual and family therapy, psycho-educational groups, health assessments, and food, clothing, and shelter are provided by the agency.

— A caseworker in St. Louis, MO

There is a variety of helping professions committed to helping those in need. Those professions in settings such as mental health, substance abuse, criminal justice, welfare, education, child and youth services, and legal aid, to name a few, are committed to helping clients address issues that emerge from problems in living. These professionals, committed to viewing clients from a holistic point of view, support client growth in areas such as social, physical, and mental health and financial, spiritual, educational, and vocational issues. The helping process is a fundamental way that professionals reach out to those in need and provide the support and structure necessary to influence their potential to develop and grow in positive ways. In this text we present knowledge and skills that will help you prepare to help others.

This chapter introduces you to a model of helping that guides many professionals who work in human service delivery. Helping is a purposeful undertaking that generally moves through three phases. We say “generally” because people are often unpredictable, problems or situations change, or services are disrupted for other reasons. The three phases of this helping model are not discrete categories with specific time limits. Rather, they illustrate the flow of the helping process that is individualized to each person, situation, or both.

This chapter also introduces the three components of the helping process: case review, documentation and report writing, and client participation. Both a strengths-based approach to the process and the ethical considerations that undergird the process are important parts of this chapter. Focus your reading and study on the following objectives, which you should be able to accomplish after reading the chapter.

Phases of the Helping Process

· ■ List the three phases of the helping process.

· ■ Identify the two activities of the  assessment phase .

· ■ Illustrate the role of data gathering in assessment and planning.

· ■ Describe the helper’s role in implementation.

Three Components of the Helping Process

· ■ Define case review and list its benefits.

· ■ Support the need for documentation and report writing.

· ■ Trace the client’s participation in the three phases of the helping process.

Strengths-Based Approach to the Helping Process

· ■ Describe this approach as it relates to each phase of the helping process.

· ■ Discuss the advantages of this approach.

Ethical Considerations

· ■ List the principles that undergird professional practice.

· ■ Summarize the limitations of codes of ethics.

At times, learning about a new concept or process is difficult without a concrete example to illustrate what the process looks like in the real world. With this in mind, we would like to introduce you to the phases of the helping process through the experience of Roy Johnson, a client working with several helping professionals to address major difficulties he encounters. Roy’s experience is based upon a client that we know who has been involved in the human service delivery system for years. He has given us permission to adapt his experiences to illustrate the nature of the helping process.

The section that follows introduces the three phases of the helping process. The case of Roy Johnson illustrates each phase.

Phases of the Helping Process

The three phases of the helping process are assessment, planning, and implementation (see  Figure 1.1 ). Each phase will be discussed in detail in later chapters. Human service delivery has become increasingly complex in terms of the number of organizations involved, government regulations, policy guidelines, accountability, and clients with multiple problems. Therefore, the helping professional needs an extensive repertoire of knowledge, skills, techniques, and strategies to serve clients effectively.

Let’s see how these phases occur in three different settings.

·  I am a case coordinator. My agency has initial responsibility for all children who come through the juvenile court system. We begin each case with an assessment. I gather school and medical records and prior psychological evaluations. Because I want to find out as much as possible about a child, I will visit the home, interview teachers and school counselors, or arrange for an evaluation.

Figure 1.1 The Helping Process

The planning process helps the staff at another agency located in the Bronx, NY, decide how and why to provide services. The agency director says:

·  It seems like our clients want to do everything all at once but we encourage them to take one day at a time. Steps are very important so that they don’t get overwhelmed and end up failing. This is something we talk with them about and encourage them to do.

A social worker who provides frontline assessments and referrals for emergency admissions at a metropolitan Houston hospital describes patient placements as the implementation phase of his work.

·  In a nutshell, my job is to figure out what’s going on and where the patient can go. Most of the people I work with come to the emergency room involuntarily, often brought by the police. I do all the paperwork and then I find a placement.

As you can see, the responsibilities at each phase vary, depending on the setting and the helper’s job description. It is important to understand that the three phases represent the flow of the helping process rather than rigidly defined steps to successful case closure. An activity that occurs in the first phase may also appear in the second or third phases of planning and implementation. Other key components appear throughout the process, including case review, report writing and documentation, and client participation. Ultimately, the goal of the helping process is to empower clients to manage their own lives as well as they are able. The case of Roy Johnson shows how this happens.

As stated earlier, Roy Johnson is a real person, but his name and other identifying information have been changed. The case as presented here is an accurate account of Roy’s experience with the human service delivery system. His case exemplifies the three phases of the helping process. The following background information will help you follow his case through assessment, planning, and implementation.

Roy referred himself for services after suffering a back injury at work. He was 29 years old and had been employed for five years as a plumber’s assistant; he hurt his back lifting plumbing materials. After back surgery, he wanted help finding work. Although he had received a settlement, he knew that the money would not last long, especially since he had contracted to have a house built. He heard about the agency from a friend who knew someone who had received services there and was now working. The agency helps people with disabilities that limit the kind of work they can do. An important consideration in accepting a person for services at the agency is determining whether services will enable that person to return to work. Roy’s case was opened at the agency; we will follow it to closure.

Assessment

The  assessment  phase of the helping process is the diagnostic study of the client and the client’s environment. It involves initial contact with an applicant as well as gathering and assessing information. These two activities focus on evaluating the need or request for services, assessing their appropriateness, and determining eligibility for services. Until eligibility is established, the individual is considered an applicant. When eligibility criteria have been met, the appropriateness of service is determined and the individual is accepted for services, then he or she becomes a client. You will read more about assessment in  Chapters Two  and  Three .

The  initial contact  is the starting point for gathering and assessing information about the applicant to establish eligibility and evaluate the need for services. In most organizations, the data gathered during the initial contact is basic and demographic: age, marital status, educational level, employment information, and the like. Other information may be obtained to provide detail about aspects of the client’s life, such as medical evaluations, social histories, educational reports, and references from employers.

·  Roy was self-referred to the agency. He initiated contact by telephoning for an appointment. Fortunately, a helping professional was able to see him that week, so he made an appointment for May 24 at 10:30 A.M. He was sent a brochure about the agency and a confirmation of his appointment. When he arrived at the agency, Roy completed an application for services. The agency believes the applicant should supply the information in this initial information gathering. Roy was able to complete the form without too much trouble, although he wasn’t sure how to answer the question about where he had heard about the agency. He didn’t know the name of his friend’s friend. The receptionist helpfully told him to write in “self-referral.” She suggested that he leave any questions blank if he wasn’t sure about the response. She also asked him not to sign.

·  Roy had brought a copy of a letter prepared by his orthopedic surgeon, Dr. Alderman, for his attorney a year earlier (see  Figure 1.2 ). Dr. Alderman had expressed the opinion that Roy would be left 10 percent disabled as a result of the injury. Dr. Alderman was also careful to clarify that Roy’s condition did not reflect a preexisting disability, even though he had suffered back problems previously. Tom Chapman, the helper who saw Roy, made a copy of the letter and returned Roy’s copy to him.

During the initial contact, the helper determines who the applicant is, begins to establish a relationship, and takes care of such routine matters as filling out the initial intake form. An important part of getting to know the applicant is learning about the individual’s previous experiences with helping, his or her strengths, his or her perception of the presenting problem, the referral source, and the applicant’s expectations. As these matters are discussed, the helper uses appropriate verbal and nonverbal communication skills to establish rapport with the applicant.

Skillful use of interviewing techniques facilitates the gathering of information and puts the applicant at ease. The helper makes the point at the conference that the client is considered an expert and that self-reported information is very important. By providing information about routine matters, the helper demystifies the process for the applicant and makes him or her more comfortable in the agency setting. Some of the routine matters addressed during the initial meeting are completing forms, gathering insurance information, outlining the purpose and services of the agency, giving assurances of confidentiality, and obtaining information releases.

Documentation records the initial contact. In the agency Roy went to, helpers fill out a Helping Professional’s Page (see  Figure 1.3 ), which describes the initial meeting.

·  Although Dr. Alderman’s letter provided helpful information about Roy’s presenting problem, agency guidelines stated that all applicants must have a physical examination by a physician on the agency’s approved list. Mr. Chapman also felt that a psychological evaluation would provide important information about Roy’s mental capabilities. He discussed both of these with Roy, who was eager to get started. Mr. Chapman asked Roy to sign a form that permits release of information from the external evaluation. As Roy prepared to leave, Mr. Chapman explained that it would take time to process the forms and review his application for services. He would be in touch with Roy very soon, explaining the next steps.

Figure 1.2 Dr. Alderman’s Letter

If the applicant is accepted for services, the client and the helper will become partners in reaching the goals that are established. Therefore, as they work through the initial  information gathering  and routine agency matters, it is important that they identify and clarify their respective roles, as well as their expectations for each other and the agency. From the first contact, client participation and service coordination are critical components in the success of the process. The helper must make clear that the client is to be involved in all phases of the process. A skillful helper makes sure that client involvement begins during the initial meeting (see  Figure 1.4 ).

Figure 1.3 Helping Professional’s Page

In Roy’s case, the helper reviewed the application with him. There were some blanks on the application, and they completed them together. Roy had not been sure how to respond to the questions about primary source of support and member of his household. As Roy elaborated on his family situation, the helper completed these items. Roy felt positive about his interactions with Tom Chapman because Tom listened to what he said, accepted his explanations, and showed insight, empathy, and good humor.

Figure 1.4 Tom Chapman’s Memo

In gathering data, the helper must determine what types of information are needed to establish eligibility and to evaluate the need for services. Once the types of information are identified, the helper decides on appropriate sources of information and data-collection methods. His or her next task is making sense of the information and data-collection methods. In these tasks, assessment is involved: The helper addresses the relevance and validity of data and pieces together information about problem identification, eligibility for services, appropriateness of services, plan development, service provision, and outcomes evaluation. During this process the helper checks and rechecks the accuracy of the data, continually asking, “Does the data provide a consistent picture of the client?”

Client participation continues to play an important role throughout the information-gathering and assessment activities. In many cases, the client is the primary source of information, giving historical data, perceptions about the presenting problem, and desired outcomes. The client also participates as an evaluator of information, agreeing with or challenging information from other sources. This participation establishes the atmosphere to foster future client empowerment.

·  The helper needed other information before a certification of eligibility could be written. In addition to Dr. Alderman’s letter, a general medical examination, and a psychological evaluation, the helper requested a period of vocational evaluation at a regional center that assesses people’s vocational capabilities, interests, and aptitudes. Tom Chapman had worked with all these professionals before, so he followed up the written reports he received with further conversations and consultations. Following a two-week period at the vocational center, the evaluators met with Roy and Mr. Chapman to discuss his performance and make recommendations for vocational objectives. When the report was completed, Mr. Chapman and Roy met several times to review information, identify possibilities, and discuss the choices available to Roy. Mr. Chapman’s knowledge of career counseling served him well as he and Roy discussed the future. Unfortunately, an unforeseen complication occurred, delaying the delivery of services. Tom Chapman changed districts, and another helper, Susan Fields, assumed his caseload. Meanwhile, Roy moved to another town to attend school. Although he was still in the same state, Roy was now about 200 miles from the helping professional with whom he worked. While Roy was attending his first semester at school in January, Ms. Fields completed a certificate of eligibility for him. This meant that he was accepted as a client of the agency and could now receive services. In May, his case was transferred to another helper (his third) in the town where he lived and attended school.

Planning

The second phase of the helping process is  planning , which is the process of determining future services in an organized way. When planning begins, the agency has usually accepted the applicant for services. The individual has met the eligibility criteria and is now a client of the agency. During this planning process, the helper and the client turn their attention to developing a service plan and arranging for service delivery. Client participation continues to be important as desired outcomes are identified, services suggested, and the need for additional information determined. The actual plan addresses what services will be provided and how they will be arranged, what outcomes are expected, and how success will be evaluated.

A plan for services may call for the collection of additional information to round out the agency’s knowledge of the client. Some helping professionals suggest that the service-delivery process is like a jigsaw puzzle, with each piece of the information providing another clue to the big picture. During this stage, the helper may realize that a social history, a psychological evaluation, a medical evaluation, or educational information might provide the missing pieces. You will read more about this information in a later chapter. The plan identifies what services are needed, who will provide them, and when they will be given. The helper must then make the appropriate arrangements for the services.

During the assessment phase, Tom Chapman did a comprehensive job of gathering information about Roy. When Roy was accepted for services, the task facing him and his new helper was to develop a plan of services. Clarity and succinctness characterize the service plan, which the helper and the client complete together, emphasizing the client’s input in the process. The plan lists each objective, the services needed to reach that objective, and the method or methods of checking progress.

Suppose that Tom Chapman had believed that a psychological evaluation was unnecessary and had been able to establish eligibility solely on the basis of the medical and vocational evaluations. Susan Fields, the new helper, might find that a psychological evaluation would be beneficial, especially since the agency was contemplating providing tuition and support for training. One objective of the plan would then be to provide a psychological evaluation of the client. This is an example of continuing to gather data during the planning phase, as well as continuing to assess the reliability and validity of the data.

Roy’s plan indicates that he is eligible for services and meets agency criteria. His program objective, business communications, was established as a result of evaluation services, counseling sessions with Mr. Chapman, and Roy’s stated vocational interests (see Figure 1.5 ). The three stated intermediate objectives will help Roy achieve the program objective.

Figure 1.5 Service Plan

The plan also provides a place to identify the responsibilities of Roy and the agency in carrying out the plan. Many agencies take very seriously the participation of the client in the development of the plan, even asking that the client sign it, as well as the helper.

Once the plan is completed, the helper begins to arrange for the provision of services. He or she must review the established network of service providers. Experienced helpers know who provides what services and who does the best work. Nonetheless, they should continue to develop their networks. For beginning helpers, the challenge is to develop their own networks: identifying their own resources and building their own files of contacts, agencies, and services. A later chapter provides information about developing, maintaining, and evaluating a network of community resources.

Implementation

The third phase of the helping process is  implementation , when the service plan is carried out and evaluated. It starts when service delivery begins, and the helper’s task becomes either providing services or overseeing services and assessing the quality of services. He or she addresses the questions of who provides each service, how to monitor implementation, how to work with other professionals, and how to evaluate outcomes.

In general, the approval of a supervisor may be needed before services can be delivered, particularly when funds will be expended. Many agencies, in fact, have a cap (a fee limit) for particular services. In addition, a written rationale is often required to justify the service and the funds. As resources become increasingly limited, agencies redouble their efforts to contain the costs of service delivery. In Roy’s case, the agency’s commitment to pay his training tuition represented a significant expenditure. Susan Fields submitted the plan and a written rationale to the agency’s statewide central office for approval.

Who provides services to clients? The answer to this question often depends on the nature of the agency. Some are full-service operations that offer a client whatever services are needed in-house. For example, the helper might provide counseling, career exploration, or education. As a rule, however, the client does not receive all services from a single helper or agency. It is usually necessary for him or her to go to other agencies or organizations for needed services. This makes it essential for the helper to possess referral skills, knowledge of the client’s capabilities, and information about community resources.

No doubt you remember that Roy’s first helper, Tom Chapman, arranged for a psychological evaluation. Many agencies like Tom’s have so many clients needing psychological evaluations that they hire a staff psychologist to do in-house evaluations of applicants and clients. School systems, for example, employ their own school psychologists. Other agencies simply contract with individuals—in this case, licensed psychological examiners or licensed psychologists—or with other agencies to provide the service. Whatever the situation, the helper’s skills in referral and in framing the evaluation request help determine the quality of the resulting evaluation.

Another task of the helper at this stage is to monitor services as they are delivered. This is important in several respects: for client satisfaction, for the effectiveness of service delivery, and for the development of a network. Monitoring is doubly important because of the personnel changes that constantly occur in human service agencies. Moreover, there may be a need to revise the plan as problems arise and situations change.

The implementation phase also involves working closely with other professionals, whether they are employees of the same agency or another organization. A helper who knows how to work successfully with other professionals is in a better position to make referrals that are beneficial to the client. These skills also contribute to effective communication among professionals about policy limitations and procedures that govern service delivery, the development of new services, and expansion of the service delivery network.

Perhaps there is no other point in service delivery at which the need for flexibility is so pronounced. For example, during the implementation stage it often becomes necessary to revise the service plan, which must be regarded as a dynamic document to be changed as necessary to improve service delivery to the client. Changes in the presenting problem or in the client’s life circumstances, or the development or discovery of other problems, may make plan modification necessary. Such developments may also call for additional data gathering.

·  In his second semester at school, Roy heard about a course of study that prepared individuals to be interpreters for the deaf. This intrigued him, because he was already proficient in sign language. His mother was severely hearing impaired, and as a child, Roy signed before he talked. He also thought back to the evaluation staff meeting, at which the team discussed the possibility of making interpreter certification a vocational objective for him. Roy liked the interpreting program and the instructors, so he applied to the program. The change in vocational objective made it necessary to modify his plan. His helper (by now, his fourth) revised the plan at the next annual review to include his new vocational objective of educational interpreting.

Three Components of the Helping Process

Case review, report writing and documentation, and client participation appear in all three phases of the helping process; they are discussed in detail in later chapters. Here we introduce the concepts by examining how each applies to Roy’s case.

Case review  is the periodic examination of a client’s case. It may occur in meetings between the helper and the client, between the helper and a supervisor, or in an interdisciplinary group of helpers, called a staffing or case conference. A case review may occur at any point in the helping process, but it is most common whenever an assessment of the case takes place. Case review is an integral part of the accountability structure of an organization; its objective is to ensure effective service delivery to the client and to maintain standards of quality care.

Roy’s case was reviewed in several ways. Each time a new helper assumed the case (unfortunately, this was often), a review was conducted. There were also reviews on the occasion of the two professional contacts Roy had per semester. At the end of each semester, his grades were checked—also part of the case review. The staffing related to Roy’s vocational evaluation is an example of case review by a team. In this case, the client was an active participant in the case review. Roy also participated in developing the service plan, which involved a review of the information gathered, the eligibility criteria, and the setting of objectives. The agency serving Roy implemented the important component of case review in various ways at different times throughout the process.

An important part of case review is the documentation of the case.  Documentation  is the written record of the work with the client, including the initial intake, assessment of information, planning, implementation, evaluation, and termination of the case. It also includes written reports, forms, letters, and other material that furnish additional information and evidence about the client. The particular form of documentation used depends on the nature of the agency, the services offered, the length of the program, and the providers. A  record is any information relating to a client’s case, including history, observations, examinations, diagnoses, consultations, and financial and social information. Also important are “all reports pertaining to a client’s care by the provider, reports originating from orders written within the facility for tests completed elsewhere, client instruction sheets, and forms documenting emergency treatment, stabilization, and transfer” (Mitchell,  1991 , p. 17). The helper’s professional expertise must include documenting appropriately and in a timely manner and preparing reports and summaries concisely but comprehensively.

Roy’s file includes many different types of documentation. The written record may include computer forms, applications for services, helpers’ notes, medical evaluations, reports, and letters. Other documentation in Roy’s file might be a psychological evaluation, a vocational evaluation, specialized medical reports, and medical updates. In Roy’s case, all this documentation may turn out to be indispensable because, during his time as a client, he worked with five different helpers. For continuity of service, good case documentation is essential.

Client participation  means the client takes an active part in the helping process, thereby making service delivery more responsive to client needs and enhancing its effectiveness. In some cases a partnership is formed between the helper and the client; an important result of this partnership is  client empowerment . One of the many factors involved in forming a partnership with the client is clear communication, or two-way communication. The helper must explain to the client his or her goals, purposes, and roles as defined by the agency. The helper encourages the client to define his or her goals, priorities, interests, strengths, and desired outcomes. At this point the client also commits to assuming responsibility within the helping process. As client participation continues and the partnership develops, it is helpful to have knowledge of subcultures, deviant groups, reference groups, and ethnic minorities so as to communicate effectively with the client about roles and responsibilities. Other factors can affect client involvement, including the timing, setting, and structure of the helping process. Minimizing interruptions, inconveniences, and distractions enhances client participation.

Encouraging client participation has identifiable components. The first is the initial contact between the client and the helper. It is easier to involve clients who initiate the contact for help, as Roy did, because they usually have a clearer idea of what the problem is and are motivated to do something about it. In Roy’s case, the clarification of roles and responsibilities occurred at three points in the assessment phase. Roy and his helper were able to talk about the agency and the services available, and the helper encouraged Roy to talk about his goals, motivations, and interests. When Roy completed his application, the helper reviewed it with him, especially the statement at the bottom of the second page. On signing the statement, the client voluntarily places himself or herself in the care of the agency. With this agreement come roles and responsibilities for both the client and the helper, which the helper reviews at that point. A second opportunity to clarify roles and responsibilities comes with the completion of a service plan. Both the client and the helper sign the service plan, which designates the responsibility for each task and the time frame for completion of each service.

The final phase of client participation comes at the termination of the case. At this time, the client and the helper together review the problem, the goals, the service plan, the delivery of services, and the outcomes. They may also discuss their roles in the process. Thus, in terms of client participation, termination means more than just closing the case. It is an assessment of the client’s progress toward self-sufficiency, the ultimate goal of client empowerment. Self-sufficiency is defined differently for each client.

Strengths-Based Approach to the Helping Process

 strengths-based approach  to helping focuses on the talents, skills, knowledge, interests, and dreams of an individual as a way to empower, motivate, and engage internal and environmental supports (Saleebey,  2008 ). Helpers use a strengths-based approach during assessment, planning, and implementation as a way to engage the client in the helping process. In this section are exercises that will help you apply the strengths-based approach to the helping process.

Assessment

A strengths-based approach to the assessment phase focuses on the positive characteristics, abilities, and experiences of the client to build upon them in addressing current problems. The counselor identifies these by asking clients to recall how they have solved problems in the past and to describe successes at home, school, work, and in relationships. This discussion is part of the problem-identification phase but shifts the emphasis from problems or deficit thinking to a more positive, client-focused position.

This approach to assessment takes time and calls for patience and facilitation from the helper. There is a dual focus at this point. One is to collect information about the client’s needs and resources; the second is to assess client functioning and the client’s social network, for example. In the strengths-based approach, the helper is most interested in the client’s resources and abilities. To identify these, the client may need prompting to recall past successful behaviors and situations. The following examples of statements or questions encourage this recall: “Tell me about a time when you faced a similar problem.” “What do you consider your most important ability?” “What have you learned from your friends and family?” “What do you enjoy doing?”

Taking time to explore the client’s responses has other benefits. Identifying strengths fosters motivation. For example, focusing on positives rather than negatives empowers the client to believe that change is possible and that he or she has the abilities and resources to make this happen. This positive approach also helps build rapport and the relationship between the client and the helper. The client leaves this session with hope that his or her needs will be met and with confidence in the helper and the relationship.

During this phase, the helper also assesses the client’s readiness for change in the areas the client has identified. Older models of helping depended on the helper to inform the client what to do. The noncompliant client was then labeled as resistant. Strengths-based approaches consider change as a process that begins with two stages. The first is precontemplation, at which point there has been no thought about change, and the second is contemplation, where considering change begins, although probably with some ambivalence (Norcross, Prochaska, & DiClemente,  1994 ).

There are a number of tools to assist with strengths identification. They include questionnaires, surveys, and forms that may be completed by the client, the family, the helper, or a combination of those involved.  Figure 1.6  is an example of a simple strengths-identification form. Guidelines of assessing strengths, detailed in  Figure 1.7 , help client and helper identify areas of perceived strength. These guidelines are based upon the sources of strengths (Saleebey,  2008 ). Other approaches are more complex and encompass the following seven domains: living arrangements, leisure/recreational, vocational/educational, health/medical, social support, emotional/behavioral, and financial (Rapp & Goscha,  2006 ). Whatever the approach during the assessment phase, the goal of the strengths-based approach is the identification of client strengths and resources.

Planning

The second phase of the helping process is planning. An understanding of strengths is essential to effectively plan. The strengths, abilities, and resources of the client become part of the plan development. In addition, all environments contain resources, and these are identified and incorporated into the planning process. These may exist in the home, the extended family, the place of employment, the place of worship, the community, or a mix of several of these. Increasing the number of available resources identified has a direct bearing on the success of the plan: the more resources to support the client’s efforts, the greater the possibilities for change.

During this phase the client–helper collaboration continues and becomes a stronger and more positive force in the helping process. A critical part of this collaboration is client participation in determining both short-term and long-term goals that are compatible with the client’s values and strengths. These goals are formulated realistically given the client’s abilities and available resources. And they are stated positively—again, a basic tenet of the strengths-based approach. Finally, the client provides input about updates based on changes in any conditions that affect the client, the plan, and the process. Assuming this responsibility engenders client participation and is one way that the transfer of helping responsibilities to the client occurs.

Implementation

Several approaches to implementation are grounded in client strengths. Among them are harm reduction, solution-focused intervention, cognitive-behavioral strategies, and motivational interviewing. The hallmark of any strengths-based intervention is choice. Specifically, the client has options in terms of the goals determined during the planning phase, the interventions or methods employed to bring about change, and the context of intervention (e.g., outpatient, inpatient, group, individual). The possibilities available to the client emphasize the values of self-determination and responsibility. The helper maximizes any benefits of these choices by respecting the client’s preferences and choice, further solidifying the relationship and affirming the client’s active role in the helping process.

Figure 1.6 Strengths Identification Form

Figure 1.7 Sources of Strengths

Another critical component of intervention is incorporating the resources that have been identified. These may be community-based resources, such as services provided by other agencies for which the client is eligible, or the resource may be one or more family members who will support the client’s efforts. In fact, the resource may have already been available but not directed to or activated for the client’s benefit. Making use of every available support enhances the client’s chances for success.

Let’s examine a specific intervention to see how it works.  Motivational interviewing  is a strategy that enhances the client’s desire to change by exploring and resolving ambivalence (Van Wormer & Davis,  2003 ). Although first used with problem drinkers, its use has expanded to a number of different problems, including smoking, bulimia, and domestic violence, and to a variety of settings such as medical practice, child welfare, and community-based organizations. Its goal is to help clients change by providing a way for them to see themselves and the costs of their behavior and to find the motivation to change the targeted behaviors. Motivational interviewing facilitates client change not by admitting the problem or finding solutions but rather by focusing on identifying what is preventing the client from changing.

The goal of motivational interviewing strategies is to increase motivation, not to get answers. The interview begins by determining the client’s current level of motivation or readiness to change. One way to determine this is to ask, “If on a scale of 1 to 10, 1 is not at all motivated to give up smoking and 10 is 100% motivated to give it up, what number would you give yourself at the moment?” (Van Wormer & Davis,  2003 , p. 80). Following up with an inquiry about “why a 4 rather than a 1” will lead to the identification of positive reasons for change. Asking “What would it take for your confidence or motivation to move from a 4 to a 5,” is another way to get the client to think about what he or she needs to increase motivation. These techniques encourage the client to identify values and goals for behavior change and to resolve any ambivalence about changing.

The helper’s role during this process is to be empathic, avoiding judgments and arguments. It is also important for the helper to articulate discrepancies between the client’s words, behaviors, and goals and to direct the client’s attention to an exploration of these discrepancies: “You say you want to quit smoking yet you keep a pack of cigarettes in your car. Tell me about that.” Using the client’s own words makes an impact on the client and prompts the client’s recognition and exploration of the discrepancy. Any resistance or reluctance is a natural part of change and is met with “It is up to you” or “What you do is really your decision.”

This brief overview of motivational interviewing enables you to see how it uses client strengths and client participation in changing. It differs from the traditional approaches or interventions that begin with problem identification, end with resolution, and involve confronting clients or persuading them that they must change. Often, these approaches actually increase resistance.

Ethical Considerations

Permeating the helping process is a commitment to ethical standards. Whatever the profession, whether it be counseling, health, human services, nursing, psychology, or social work, helping behavior is grounded in similar principles that focus on the way helpers work with the recipients of their services. These principles represent commitments to the client’s right to self-determination, to do no harm, to promote fairness and equal access to services, to be responsible to the client, and to be honest.

Codes of ethics , or ethical standards, have been developed by professions to operationalize these commitments in order to provide guidelines for practice. Examples are the Ethical Standards for Psychologists (American Psychological Association), the Ethical Standards for School Counselors (American School Counselor Association), the Code of Ethics for Rehabilitation Counselors (Commission on Rehabilitation Counselor Certification), and the Ethical Standards of Human Service Professionals (National Organization for Human Services). Their purpose is to clarify the helper’s responsibility to clients, employers, and society.

Codes of ethics pose two challenges. First, a profession’s code of ethics is binding only on members of the group that adopts it. Those who are not members are not bound by the code. Second, it is impossible for a code to cover every possible situation that could arise in the helping process. The following quotes present some real ethical dilemmas that helpers encounter:

·  All the people we work with want everything to be confidential. This is a problem for them and for us when we have to report something.

Settlement House Worker, Bronx, NY

·  Clients who don’t want our help are challenging. It’s difficult to watch a client fail, especially when there is potential for improvement and stability.

Case Manager, Los Angeles

·  It’s a difficult situation when the family is against us. For example, we have a client whose family tells her she shouldn’t be on medication. She listens to them but what they tell her isn’t always in her best interest.

Mental Health Professional, Knoxville

As you can see from these quotes, the helping process often requires a delicate balance of consideration to the client, the family, the agency or organization, laws and regulations, and professional codes of ethics. These conflicting interests can create crises that require the helper to make difficult choices. The situations just described reflect some of the tensions helpers face. Because changes occur in laws and regulations, professional practices, and standards of practice, codes of ethics also change, adding complexity and presenting new challenges to professionals. For example, the use of technology has required a rethinking of assuring confidentiality, and the realities of shifting population demographics have created the need for competencies in multicultural counseling.

Ethics in helping professions is a complex issue that is addressed both in courses and throughout curricula and is mandated by academic accrediting bodies and certification and licensure boards. As you read the following chapters about the phases of the helping process, think about the ethical dilemmas that might occur.

CHAPTER SUMMARY

Managing client services is an exciting and challenging responsibility for helping professionals. To assist clients with multiple problems, helping professionals must know the process of helping and be able to use it. The process can be adapted to many different settings, for work with a variety of populations.

The three phases of the helping process—assessment, planning, and implementation—each represent specific responsibilities assumed by the helper. The process of helping is nonlinear; for example, a helper may make some assessments early on and return to conduct assessment during the planning and implementation work with the client. Three components of the helping process appear in all three phases of helping: case review, report writing and documentation, and client participation. Note that the first two components also include interaction with and participation by the client. These components require ongoing evaluation and written documentation of the helping process.

The strengths-based approach differs from older models of helping that are problem-based or deficit-based assessments, followed by planning and implementation that target the problem(s). These older models have less client engagement and participation, are often provider driven, and focus on negative events or characteristics. They may actually lessen the client’s ability to solve his or her own problems and encourage dependency on the helper to define problems and identify strategies to resolve the problem. Both older models and strengths-based approaches attempt to match clients and resources. The strengths-based approach also helps clients become their own helpers, assuming responsibility for themselves and their problems and motivating them to act in their own best interests.

KEY TERMS

Assessment

Case review

Client empowerment

Client participation

Codes of ethics

Documentation

Implementation

Information gathering

Initial contact

Motivational interviewing

Planning

Record

Strengths-based approach

REVIEWING THE CHAPTER

1.

Distinguish between the terms applicant and client.

2.

What should be accomplished during the assessment phase?

3.

What occurs during the initial contact between the helper and the individual seeking services?

4.

Describe the routine matters that are discussed during the initial contact.

5.

Identify the types of information that are gathered during the initial interview.

6.

Using the case of Roy Johnson, discuss the advantages of a partnership between the helper and the client.

7.

Describe the helper’s activities during the planning phase.

8.

Why is flexibility so important during the implementation phase?

9.

Define case review.

10.

List the three keys to successful case review.

11.

Why is documentation important in service coordination?

12.

How can the helper promote client participation?

13.

Describe how the strengths-based approach applies to assessment, planning, and implementation.

14.

How will a client’s resistance affect his or her participation in the service coordination process?

15.

What is the purpose of a code of ethics or ethical standards?

QUESTIONS FOR DISCUSSION

1.

From your own work and study of helping, what evidence do you have of the importance of assessment and planning?

2.

If you were a helper, what three principles would guide your work? Provide a rationale for your choices.

3.

Describe Roy’s strengths and how they might impact the helping process.

4.

What ethical dilemmas might you encounter in Roy’s case?

REFERENCES

Mitchell, R. W. (1991). Documentation in counseling records. Alexandria, VA: American Association for Counseling and Development.

Norcross, J. C., Prochaska, J. O., & DiClemente, C. C. (1994). Changing for good. NY: Avon.

Rapp, C. A., & Goscha, R. J. (2006). The strengths model: Case management with people with psychiatric disabilities (2nd ed.). Oxford Press: Oxford.

Saleebey, D. (2008). The strengths perspective in social work practice (5th ed.). Boston: Allyn & Bacon.

Van Wormer, K., & Davis, D. R. (2003). Addiction treatment: A strengths perspective. Pacific Grove, CA: Brooks/Cole/Thomson.

CHAPTER TWO The Assessment Phase

·  Referral, screening, and assessment begin our work with HIV clients. We get a referral, then screen to see if there is a match between the referrals and the family service center. This includes a home visit and verification of HIV status. An assessment of the family follows. Its purpose is to identify needs.

—Caseworker, Bronx, NY

Assessment means appraisal or evaluation of a situation, the person(s) involved, or both. As the initial stage in helping, assessment generally focuses on identifying the problem and the resources needed to resolve it. Focusing on the people who are involved includes attention to client strengths that can be a valuable resource to encourage client participation and facilitate problem solving. The benefits of the strengths-based approach to assessment were discussed in  Chapter One . As the opening example shows, data are gathered and assessed at this phase to show the applicant’s problem in relation to the agency’s priorities. Identifying possible actions and services and determining who will handle the case are also part of the assessment phase. In this example, a preliminary screening follows the referral. This chapter explores the assessment stage of the helping process: the initial contact with an applicant for assistance, the interview as a critical component in data gathering, and the case record documentation that is required during this phase. You can refer to  Figure 2.1  to see the place assessment has in the helping process. The assessment phase concludes with the evaluation of the application for services. For each section of the chapter, you should be able to accomplish the following objectives.

Application for Service

· ■ List the ways in which potential clients learn about available services.

· ■ Compare the roles of the helper and the applicant in the interview process.

· ■ Define interview.

· ■ Distinguish between structured and unstructured interviews.

· ■ State the general guidelines for confidentiality.

· ■ Define the helper’s role in evaluating the application.

· ■ List the two questions that guide assessment of the collected information.

Case Assignment

· ■ Compare the three scenarios of case assignment.

Documentation and Report Writing

· ■ Distinguish between process recording and summary recording.

· ■ List the content areas of an intake summary.

· ■ State the reasons for case or staff notes.

Figure 2.1 The Helping Process

Application for Services

Potential clients or applicants learn about available services in a number of ways. Frequently, they apply for services only after trying other options. People having problems usually try informal help first; it is human nature to ask for help from family, friends, parents, and children. Some people even feel comfortable sharing their problems with strangers waiting in line with them or sitting beside them. A familiar physician or pastor might also be consulted on an informal basis. On the other hand, some people avoid seeking informal help because of embarrassment or fear of loss of face or disappointment.

Previous experiences with helping agencies and organizations also influence the individual’s decision to seek help. Many clients have had positive experiences with human service agencies, resulting in improved living conditions, increased self-confidence, the acquisition of new skills, and the resolution of interpersonal difficulties. Others have had experiences that were not so positive, having encountered helpers who had different expectations of the helping process, delivered unwanted advice, lacked the skills needed to assist them, were inaccessible, or never understood their problems. Increasingly, clients may also encounter local, state, and national policies that may make it difficult to get services. An individual’s other prior life experiences also play a role in the decision to seek help.

An individual who does decide that help is desirable can find information about available services from a number of sources. Informal networks are probably the best sources of information. Family, friends, neighbors, acquaintances, and fellow employees who have had similar problems (or who know someone who has) are people trusted to tell the truth about seeking help. Other sources of information are professionals with whom the individual is already working, the media (posters, public service announcements, and advertisements), the telephone book, and the Internet. Once people locate a service that seems right, they generally get in touch on their own (self-referral).

Other individuals may be referred by a human service professional if they are already involved with a human service organization but need services of another kind. They may be working with a professional, such as a physician or minister, who also makes referrals. These applicants may come willingly and be motivated to do something about their situation, or they may come involuntarily because they have been told to do so or are required to do so. The most common referral sources for mandated services are courts, schools, prisons, protective services, marriage counselors, and the juvenile justice system. These individuals may appear at the agency but ask for nothing, even denying that a problem exists.

The following examples illustrate the various ways referral can occur. The first individual works at a community-based agency.

·  The center is open five days a week year round. Our mobile outreach initiative identifies clients. We use a van or bicycles to find and interact with people on the streets who are homeless and need our services.

—Social Worker, St. Louis

The second quote is from a caseworker at an institution that serves the elderly in a large metropolitan city.

·  Clients come to us in several ways—from other agencies, through friends, by word of mouth, Medicaid, or the discharge planning staff.

—Caseworker, Bronx, NY

The third works at a community mental health center that coordinates services for clients with chronic mental illness. At this agency, client records are available at referral and provide important information about the client and previous services.

·  Our referrals are on paper. From that information I make a determination about fit with our criteria. If there is a fit, one of the case managers will visit the client, who is usually in the hospital. This makes him or her easier to find.

—Case Manager, Los Angeles

The final example is from a program for the homeless in Brooklyn, NY.

·  Our clients come from the homeless shelter. One of our programs serves the homeless who have employment skills. Often we go to shelters in town to tell social workers and shelter clients about the program.

—Agency Director, Brooklyn, NY

These examples illustrate the different ways in which a referral occurs. In an institutional setting, referrals are made by other professionals and departments in the institution. In other settings, referrals can also occur in-house or come from other agencies or institutions. Sometimes the referral procedure may include an initial screening by phone ( Figure 2.2 ), a committee deliberation, an individual interview, or the perusal of existing records or reports, or both. Usually, the individual who receives the referral makes sure that the necessary paperwork is included.

Not all applicants who seek help or are referred for services become clients of the agency.  Clients  are those who meet eligibility criteria to be accepted for services. An  intake interview  is the first step in determining eligibility and appropriateness.

The Interview

An  interview  is usually the first contact between a helper and an applicant for services, although some initial contacts are by telephone or letter. The first helper an applicant talks with may be an intake worker who only conducts the initial meeting, or he or she may in fact be a case manager, helping professional, counselor, or service provider. If the first contact is an intake worker, the applicant (if accepted for services) will also be assigned to a helper, who will coordinate whatever services are provided. In this text, we will assume that the intake interviewer is also the professional who will provide help.

The initial meeting or intake interview, with an applicant takes place as soon as possible after the referral. The interview is an opportunity for the helper and applicant to get to know one another, define the person’s needs or problems, and give some structure to the helping relationship. These activities provide information that becomes a starting point for service delivery, so it is important for the interviewer to be a skillful listener, interpreter, and questioner. First, we will explore what an interview is, the flow of the interview process, and two ways to think about interviews that you may conduct as part of the intake process.

Figure 2.2 Phone Screening Form

Interviewing is a critical tool for communicating with clients, collecting information, determining eligibility, and developing and implementing service plans—in all, a key part of the helping process. Primary objectives of interviewing are to help people explore their situation, to increase their understanding of it, and to identify resources and strengths. The roles of the applicant and the helper during this initial encounter reflect these objectives. The applicant learns about the agency, its purposes and services, and how they relate to his or her situation. The helper obtains the applicant’s statement of the problem and explains the agency and its services. Once there is an understanding of the problem and the services the agency offers, the helper confirms the applicant’s desire for services. The helper is also responsible for recording information, identifying the next steps in the helping process, informing the applicant about eligibility requirements, and clarifying what the agency can legally provide a client. There are three desirable outcomes of the initial interview (Kanel,  2007 ). First, rapport establishes an atmosphere of understanding and comfort. Second, the applicant feels understood and accepted. Third, the applicant has the opportunity to talk about concerns and goals.

EXACTLY WHAT IS AN INTERVIEW?

In the helping process, an interview is usually a face-to-face meeting between the helper and the applicant; it may have a number of purposes, including getting or giving information, resolving a disagreement, or considering a joint undertaking.

An interview may also be an assessment procedure. It can be a testing tool in areas such as counseling, school psychology, social work, legal matters, and employment applications. One example of this is testing an applicant’s mental status. We can also think of the interview as an assessment procedure in which one of the first tasks is to determine why the person is seeking help. An assessment helps define the problems and client strengths, and the resulting definition then becomes the focus for intervention.

Another way to think about defining the interview is to consider its content and process (Enelow & Wexler,  1966 ). The content of the interview is what is said, and the process is how it is said. Analyzing an interview in these terms gives a systematic way of organizing the information that is revealed in the interaction between the helper and the applicant. It also facilitates an understanding of the overall picture of the individual. This is particularly relevant, since many clients have multiple problems. Ivey, Ivey, and Zalaquett ( 2010 ) caution that although the terms counseling and interviewing are sometimes used interchangeably, interviewing is considered the more basic process for information gathering, problem solving, and the giving of information or advice. An interview may be conducted by almost anyone—business people, medical staff, guidance personnel, or employment helping professional. Therapeutic intervention is a more intensive and personal process, often associated with professional fields such as social work, guidance, psychology, and pastoral counseling. Interviewing is a responsibility assumed by most helpers, whereas counseling is not always their job.

HOW LONG IS AN INTERVIEW?

An interview may occur once or repeatedly, over long or short periods of time. Okun and Kantrowitz ( 2008 ) limit the use of the word interview to the first meeting, calling subsequent meetings sessions. In fact, the actual length of time of the initial meeting depends on a number of factors, including the structure of the agency, the comprehensiveness of the services, the number of people applying for services (an individual or a family), and the amount of information needed to determine eligibility or appropriateness for agency services.

A caseworker from a community action agency recalled that she had conducted an intake interview in 15 minutes. “When I was learning to be a helper, I thought I would have the time I needed for the first visit with a client” (Case Manager, Women’s Advocacy, Tennessee).

WHERE DOES THE INTERVIEW TAKE PLACE?

Interviews generally take place in an office at agencies, schools, hospitals, and other institutions. Sometimes, however, they are held in an applicant’s home. Observing the applicant in the home provides the distinct advantage of information about the applicant that may not be available in an office setting. An informal location, such as a park, a restaurant, or even the street, can also serve as the scene of an interview. Whatever the setting, it is an important influence on the course of the interview.

WHAT DO ALL HELPING INTERVIEWS HAVE IN COMMON?

There are commonalities that should occur in any initial interview. First, there must be shared or mutual interaction: Communication between the two participants is established, and both share information. The interviewer may be sharing information about the agency and its services, while the applicant may be describing the problem. No matter what the subject of their conversation is, the two participants are clearly engaged as they develop a relationship.

A second factor is that the participants in the interview are interdependent and influence each other. Each comes to the interaction with attitudes, values, beliefs, and experiences. The interviewer also brings the knowledge and skills of helping, while the person seeking help brings the problem that is causing distress. As the relationship develops, whatever one participant says or feels triggers a response in the other participant, who then shares that response. This type of exchange builds the relationship through the sharing of information, feelings, and reactions.

The third factor is the interviewing skill of the helper. He or she remains in control of the interaction and clearly sets the tone for what is taking place. The knowledge and expertise of the professional helper distinguish the helper from the applicant and from any informal helpers who have previously been consulted. Because the helping relationship develops for a specific purpose and often has time constraints, it is important for the helper to bring these considerations to the interaction, in addition to providing information about the agency, its services, the eligibility criteria, community resources, and so forth.

The Interview Process

The interview’s structure refers to the arrangement of its three parts: the beginning, the middle, and the end. The beginning is a time to establish a common understanding between the interviewer and the applicant. The middle phase continues this process, through sharing and considering feelings, behaviors, events, and strengths. At the end, a summary provides closure by describing what has taken place during the interview and identifying what will follow. Let’s examine each of these parts in more detail.

THE BEGINNING

Several important activities occur at the beginning of the interview: greeting the client, establishing the focus by discussing the purpose, clarifying roles, and exploring the problem that has precipitated the application for services, as well as client strengths. The beginning is also an opportunity to respond to any questions that the applicant may have about the agency and its services and policies. The following questions are those most frequently raised by clients (Weinrach,  1987 ).

How often will I come to see you?

Can I reach you after the agency closes?

What happens if I forget an appointment?

Is what I tell you confidential?

What if I have an emergency?

How will I know when our work is finished?

What will I be charged for services?

Will my insurance company reimburse me?

Answering these questions can lead to a discussion of the applicant’s role and his or her expectations for the helping process.

THE MIDDLE

The next phase of the interview is devoted to developing the focus of the relationship between the interviewer and the applicant. Assessment, planning, and implementation also take place at this time. Assessment occurs as the problem is defined in accordance with the guidelines of the agency. Often, assessment tends to be problem focused, but a discussion that focuses only on the client’s needs or weaknesses, or both, can be depressing and discouraging.

Spending some of the interview identifying strengths can be energizing and can result in a feeling of control. Assessment also includes consideration of the applicant’s eligibility for services in light of the information that is collected. All these activities lead to initial planning and implementation of subsequent steps, which may include additional data gathering or a follow-up appointment.

THE END

At the close, the interviewer and the applicant have an opportunity to summarize what has occurred during the initial meeting. The summary of the interview brings this first contact to closure. Closure may take various forms, including the following scenarios: (1) the applicant may choose not to continue with the application for services; (2) the problem and the services provided by the agency are compatible, the applicant desires services, and the interviewer moves forward with the next steps; and (3) the fit between the agency and the applicant is not clear, so it is necessary to gather additional information before the applicant is accepted as a client.

A technique that some helpers find successful as an end to the initial interview is a homework assignment that once again turns the applicant’s attention to strengths. Individuals may be asked questions to help identify the source of their strengths as suggested in Figure 1.7  of  Chapter One . Although this type of discussion might occur at any time in the helping process, the value in such a technique at this time is the movement that might occur from problem-oriented vulnerability to problem-solving resilience. It may also solidify the client’s intent to return and promote his or her involvement in the helping process.

Structured and Unstructured Interviews

Interviews may be classified as structured or unstructured. A brief overview of these two types of interviews is given here.  Chapter Four  will provide more in-depth information about the structured interview in connection with the discussion of skills for intake interviewing.

Structured interviews  are directive and focused; they are usually guided by a form or a set of questions that elicit specific information. The purpose is to develop a brief overview of the problem and the context within which it is occurring. They can range from a simple list of questions to soliciting an entire case history.

Agencies often have application forms that applicants complete before the interview. If the forms are completed with the help of the interviewer during the interview, the interaction is classified as a structured one. Of course, this is a good way to establish rapport and to identify strengths, but interviewers must be cautious. The interview can easily become a mere question-and-answer session if it is structured exclusively around a questionnaire. Asking yes/no questions and strictly factual questions limits the applicant’s input and hinders rapport building.

The intake interview and the mental status examination are two types of structured interviews, each of which has standard procedures. Generally, an agency’s intake interview is guided by a set of questions, usually in the form of an application. The  mental status examination  (which typically takes place in psychiatric settings) consists of questions designed to evaluate the person’s current mental status by considering factors such as appearance, behavior, and general intellectual processes. In both situations, the interviewer has responsibility for the direction and course of the interview, even though the areas to be covered are predetermined. A further look at the mental status examination illustrates the structured interview.

A mental status examination is a simple test that assesses a number of factors related to mental functioning. Sometimes agencies will use a predetermined list of questions. Others may use a test such as the Mini Mental Status Examination (MMSE). Both modalities structure the interview. Whatever the method, generally the focus is on four main components that may vary slightly in their organization: appearance and behavior, mood and affect (emotion), thought disturbances, and cognition (orientation, memory, and intellectual functioning). Some of these components may be assessed by observing the client while others require asking specific questions and listening closely to responses. For example, appearance and behavior are observable and may target dress, hygiene, eye contact, motor movements or tics, rhythm and pace of speech, and facial expressions. On the other hand, thought disturbances are based on what a client tells the examiner and his or her perception of things: “Do your thoughts go faster than you can say them?” “Do you hear voices that others cannot hear?” and “Have you ever seen anything strange you cannot explain?” The examiner takes into consideration factors such as a person’s country of origin, language skills, and educational level. Terms like “high school” and tasks like reciting former U.S. presidents may not be appropriate for all examinees.

As you read the following report, determine the results of the assessment of the four components of a mental status examination:

·  “Pops” Bellini arrived for his appointment on time. He was dressed in slacks and a shirt but appeared disheveled, with wrinkled clothing and uncombed hair. He stated that he had been homeless for six months and had not bathed in four days. He wants to work. He rocked forward when answering a question and tightly clasped his hands in his lap. He reported that he is on no medication at the present time, although he has taken “something” in the past for “nerves.” His mood was anxious and tense, wondering if he will be able to find some work. Speech was slow, clear, and deliberate. Initially he responded with a wide-eyed stare. Mr. Bellini often asked that a question be repeated; upon repetition, he provided responses that were relevant to the question. Cognition seemed logical and rational although slow. Mr. Bellini is aware of the need to find work to support himself but is concerned about his ability to perform at a job. He seems most worried about “pressures” that cause him to “freeze.”

In contrast to the structured interview, the  unstructured interview  consists of a sequence of questions that follow from what has been said. This type of interview can be described as broad and unrestricted. The applicant determines the direction of the interaction, while the interviewer focuses on giving reflective responses that encourage the eliciting of information. Helpers who use the unstructured interview are primarily concerned with establishing rapport during the initial conversation. Reflection, paraphrasing, and other responses discussed in  Chapter Four  will facilitate this.

Confidentiality

Our discussion of the initial meeting would be incomplete if we did not address the issue of  confidentiality . Human service agencies have procedures for handling the records of applicants and clients and for maintaining confidentiality; all helpers should be familiar with them. An all-important consideration is access to information.

Every communication during an interview should be confidential in order to encourage the trust that is necessary for the sharing of information. Generally, human service agencies allow the sharing of information with supervisors, consultants, and other staff who are working with the applicant. The client’s signed consent is needed if information is to be shared with staff employed by other organizations. The exception to these general guidelines is that information may be shared without consent in cases of emergency, such as suicide, homicide, or other life-threatening situations.

Applicants are frequently concerned about who has access to their records. In fact, they may wonder whether they themselves do. Legally, an individual does indeed have access to his or her record; the Federal Privacy Act of 1974 established principles to safeguard clients’ rights. In addition to the right to see their records, clients have the right to correct or amend the records. For example, the Department of Health and Human Services retains oversight for the Health Insurance Portability Accountability Act of 1996 (HIPAA), which outlines privacy regulations related to client records within the health care arena (U.S. Department of Health and Human Services, n.d.). The overriding principle of the act is that records belong to the client, not the office or agency in which they are generated or housed. Clients have access to their own records and they determine who else may view them. Agencies and offices must provide clients information about HIPAA (Notice of Privacy Practices) and must secure client authorization for release of all information.

There are two potential problem areas related to confidentiality. First, it is sometimes difficult in large agencies to limit access of information to authorized staff. Support staff, visitors, and delivery people come and go, making it essential that records are secure and conversations confidential (Hutchins & Cole Vaught,  1997 ). The second problem has to do with  privileged communication , a legal concept under which clients’ “privileged” communications with professionals may not be used in court without client consent (Corey, Corey, & Callanan,  2007 ). State laws determine which professionals’ communications are privileged; in most states, human service professionals are not usually included. Thus, the helper may be compelled to present in court any communication from the applicant or client. Sometimes it can be a challenge for the helper to explain this limitation to an applicant while trying to gather essential information. It can also be perplexing to the applicant.

Evaluating the Application for Services

During this phase, the helper’s role is to gather and assess information. In fact, this process may actually start before the initial meeting with the applicant, when the first report or telephone call is received, and continue through and beyond the initial meeting. The initial focus on information gathering and assessment then narrows to problem identification and the determination of eligibility for services. This process is influenced to some extent by guidelines and parameters established by the agency or by federal or state legislation. At this point in the process, the helper must pause to review the information gathered for assessment purposes.

Part of the assessment of available information is responding to the following questions:

Is the client eligible for services?

What problems are identified?

Are services or resources available that relate to the problems identified?

Will the agency’s involvement help the client reach the objectives and goals that have been established?

Reviewing these questions helps determine the next steps. To answer the questions and evaluate the application for services, the helper engages in two activities: a review of information gathering and an assessment of the information.

REVIEW OF INFORMATION GATHERING

Usually, the individual who applies for services is the primary source of information. During the initial meeting, the helper forms impressions of the applicant. The problem is defined, and judgments are made about its seriousness—its intensity, frequency, and duration (Hutchins & Cole Vaught,  1997 ). As the helper reviews the case, he or she considers these impressions in conjunction with the application for services, the case notes summarizing the initial contact with the client, and any case notes that report subsequent contacts. The helper learns more about the applicant’s reasons for applying for services; his or her background, strengths, and weaknesses; the problem that is causing difficulty; and what the applicant wants to have happen as a result of service delivery. The helper also uses information and impressions from other contacts. Other information in the file that may contribute to an understanding of the applicant’s situation comes from secondary sources, such as the referral source, the client’s family, school officials, or an employer. Information from secondary sources that can be part of the case file might be medical reports, school records, a social history, and a record of services that have previously been provided to the client.

An important part of the review of information gathering is to ascertain that all necessary forms, including releases, have been completed and signatures obtained where needed. It is also a good idea at this point to make sure that all necessary supervisor and agency reviews have occurred and are documented.

ASSESSING INFORMATION

Once the helper has reviewed all the information that has been gathered, the information is assessed. Many helpers have likened this part of the helping process to a puzzle. Each piece of information is part of the puzzle; as each piece is revealed and placed in the file, the picture of the applicant and the problem becomes more complete. Some describe it as “a large body of information from all kinds of different people that you have to sort through in order to identify the real issues.” In addition, a social worker in Houston suggests,

·  Sometimes, to be effective, it’s necessary to be sensitive to what is going on and what it means. This is a poor white community with many different subcultures. For example, anyone who works here needs to understand the importance of shamans and spells. Sometimes individuals and families just need a shaman to get rid of the spell. I’ve actually seen some bizarre behavior changes as a result of a shaman’s intervention.

Knowing what information is in the file, the helper’s task shifts to assessing the information. Two questions guide this activity: Is there sufficient information to establish eligibility? Is additional information necessary? In addition to answering these questions, the helper also evaluates the information in the file, looking for inconsistencies, incompleteness, and unanswered questions that have arisen as a result of the review.

IS THERE SUFFICIENT INFORMATION TO ESTABLISH ELIGIBILITY?

To answer this question, the helper must examine the available data to determine what is relevant to the determination of eligibility. The quantity of data gathered is less important than its relevance. Human service organizations usually have specific criteria that must be met to find an applicant eligible. The data must correspond to these criteria if the applicant is to be accepted for services.

The criteria for acceptance as a client for vocational rehabilitation services is a good example. Vocational rehabilitation is a state and federal program whose mission is to provide services to people with disabilities so as to enable them to become productive, contributing members of society. Essentially, the criteria for acceptance for services are the following: the individual must have a documented physical or mental disability that is a substantial handicap to employment, and there must be a reasonable expectation that vocational rehabilitation services will render the applicant fit for gainful employment.

During the assessment phase, a helping professional assesses the information gathered to determine whether the applicant has a documented disability. The next step is to document that the disability is a handicap to employment. Does the disability prevent the applicant from returning to work? Or, if the person has not been employed, does the disability prevent him or her from getting or keeping a job? If the answers are yes, the helper’s final task is to find support for a reasonable expectation that, as a result of receiving services, the applicant can be gainfully employed. This brings us to the second main question in the information assessment activity.

IS ADDITIONAL INFORMATION NECESSARY IN ORDER TO DETERMINE ELIGIBILITY FOR SERVICES?

If the answer is no, the helper and the client are ready to move to the next phase of the helping process. If the answer is yes—that is, additional information is necessary to establish eligibility—a decision is then made about what is needed and how to obtain it. In the vocational rehabilitation example, the helper examines the file for the documentation of a disability. Specifically, the helper is looking for a medical report from a physician or specialist that will establish a physical disability or a psychological or psychiatric evaluation that will establish a mental disability. If the needed information is not in the file, the helper must make arrangements to obtain the necessary reports.

Establishment of eligibility criteria is not the sole purpose of this phase. Data gathered at this time may prove helpful in the formulation of a service plan. Certainly the helper does not want to discard any information at this point; neither does he or she want to leave unresolved any conflicts or inconsistencies. Relevant, accurate information is an important part of the development of a plan. Ensuring relevance and accuracy at this point in the process saves time and effort and allows the helper and the client to move forward without delay.

Case Assignment

Once eligibility has been established and the applicant accepted for services, there are three possible scenarios, depending on the particular agency or organization. In all three, the applicant becomes a client who is assigned a helper to coordinate and/or provide services. In many instances, this helper is the same person who handled the intake interview and determination of eligibility. In some agencies, however, there are staff members whose primary responsibility is conducting the intake interview. After a review, the case is then assigned to another helper—the helping professional who assumes primary responsibility for the case and is accountable for the services given to the client, whether provided personally, by other professionals at the agency, or by helpers at a different agency.

A second scenario involves the specialized professional, a term that may refer to either level specialization or task specialization. Level specialization has to do with the overall complexity and orientation of the client and the presenting problem. Is the case under consideration simple or complex? Is it a case of simply providing requested information, or is it a multi-problem situation? Task specialization focuses on the functions needed to facilitate problem resolution. Does the case require highly skilled counseling, or is coordination sufficient?

The third scenario occurs most often in institutions where a team of professionals is responsible for a number of clients. For example, in a facility for children with cognitive disabilities clients interact daily with a staff that includes a teacher, a nurse, an activity coordinator, a helper, a cottage parent, and a social worker. These professionals work together as a team to provide services to each client.

Documentation and Report Writing

Documentation and report writing play critical roles in the assessment phase of the helping process. The main responsibilities facing the helper in this phase are identifying the problem or problems and determining the applicant’s eligibility for services. Documentation of these two responsibilities takes the form of intake summaries and staff notes. Most agencies have guidelines for the documentation of information gathered and decisions made. This section addresses the forms of documentation, their purposes, and how to write them.

Before we discuss intake summaries and staff notes, let’s distinguish between process recording and summary recording.

Process Recording and Summary Recording

 process recording  is a narrative telling of an interaction with another individual. In the assessment phase, a process recording shows what each participant has said by an accurate account of the verbal exchange, a factual description of any action or nonverbal behavior, and the interviewer’s analysis and observations. The person making the recording should imagine that a tape recorder and a camera are taking in everything that is heard or seen. Of course, because records are required to be brief and goal oriented, the helper would not attempt an exhaustive description, but this approach helps focus the recorder’s attention on accuracy and impartiality.

Process recording is a useful tool for helping professionals in training. Tape recorders, digital recorders, video cameras, and VCRs are readily available today, but many agencies and organizations don’t have them, and helpers may not have time or authorization to use the equipment. Process recording is still an effective way to hone one’s skills of direct observation.

Process recording is most often used with one-on-one interviews. It includes the following elements:

· ■  Identifying information : names, date, location, client’s case number or identifying number, and the purpose of the interview.

Paulette Maloney saw the client, Rosa Knight, for the first time on Monday, November 5, at the agency. Ms. Knight is applying for services, and the purpose of the interview was to complete the application form and inform her of the agency’s services.

· ■  Observations : description of physical and emotional climate, any activity occurring during the interaction, and the client’s nonverbal behavior.

Ms. Knight appeared in my office on time, dressed neatly in a navy dress. I asked Ms. Knight to come in, introduced myself, shook her hand, and asked her to sit down. Although there was little eye contact, she smiled shyly with her head lowered. In a soft voice, she asked me to call her Rosa. Then she waited for me to speak.

· ■  Content : an account of what was said by each participant. Quotes are helpful here, to the extent that they can be remembered.

I explained to Rosa that the agency provides services to mothers who are single parents, have no job skills, and have children who are under the age of 6. She replied, “I am a single parent with two sons who are 18 months old and 3 years old. I have worked briefly as a domestic.” I asked her how long she had worked and where. She replied that she worked about five months for a woman a neighbor knew. She quit “because the woman was always canceling at the last minute.” She related that one time when she went to work, the house was locked up and the family was out of town. During this exchange, Rosa clasped her hands in her lap and looked up.

· ■  Recorder’s feelings and reactions : sometimes this is called a self-interview, meaning that the recorder writes down feelings about and reactions to what is taking place in the interview.

I was angry about the way Rosa had been treated in her work situation. She appears to be a well-mannered, motivated young woman who genuinely wants a job so that she can be self-supporting. Her shyness may prevent her from asserting herself when she needs to. Her goal is to get out of the housing project. I wonder if my impressions are right.

· ■  Impressions : here the recorder gives personal impressions of the client, the problem, the interview, and so forth. It may also be appropriate to make a comment about the next step in the process.

Rosa Knight is a 23-year-old single mother of two sons, ages 18 months and 3 years. She has worked previously as a domestic. Particular strengths seem to be motivation and reliability. Her goal is to receive secretarial training so that she can be self-supporting and move from the projects. Based on the information she has provided during this interview, she is eligible for services. I will present her case at the next staff meeting to review her eligibility.

The other style of recording,  summary recording , is preferred in most human service agencies. It is a condensation of what happened, an organized presentation of facts. It may take the form of an intake summary or staff notes (both discussed later in this section).

Summary recording is also used for other types of reports and documentation. For example, a diagnostic summary presents case information, assesses what is known about the client, and makes recommendations. (See the Report for Juvenile Court in  Chapter Eight .)

A second example is problem-oriented recording, which identifies problems and treatment goals. This type of recording is common in an interdisciplinary setting or one with a team structure. (An example is the Psychological Evaluation, also in  Chapter Eight .)

Summary recording differs from process recording in several ways. First, a summary recording gives a concise presentation of the interview content rather than an extensive account of what was said. The focus remains on the client, excluding the interviewer’s feelings about what transpired. Summary recordings usually contain a summary section, which is the appropriate place for the writer’s own analysis. Finally, summary recording is organized by topic rather than chronologically. The interviewer must decide what to include and omit under the various headings: Identifying Information, Presenting Problem, Interview Content, Summary, and Diagnostic Impressions.

Summary recording is less time-consuming to write, as well as easier to read. It is preferred for these reasons, not to mention the fact that it uses less paper, thereby reducing storage problems. Where computerized information systems are used, a standard format makes information easy to store, retrieve, and share with others. A reminder is in order here: agencies often have their own formats and guidelines for report writing and documentation. Generally speaking, however, the basic information presented here applies across agency settings.

Intake Summaries

An  intake summary  is written at some point during the assessment phase. It is usually prepared following an agency’s first contact with an applicant, but it may also be written at the close of the assessment phase. For purposes of illustration, assume that it is written after the intake interview. At this point, the interviewer assesses what was learned and observed about the applicant. This assessment takes into account the information provided by the applicant; the mental status examination, if appropriate; forms that were completed; and any available information about the presenting problem. Client strengths are also identified at this time. The interviewer also considers any inconsistencies or missing information. While integrating the information, the interviewer also considers the questions that are presented in the previous section. Is the applicant eligible for services? What problems are identified? Are services or resources available that relate to the problems identified? Will the agency’s involvement improve the situation for the applicant?

This information is organized into an intake summary, which usually includes the following data:

· ■ Worker’s name, date of contact, date of summary

· ■ Applicant’s demographic data—name, address, phone number, agency applicant number

· ■ Sources of information during the intake interview

· ■ Presenting problem and client strengths

· ■ Summary of background and social history related to the problem

· ■ Previous contact with the agency

· ■ Diagnostic summary statement

· ■ Treatment recommendations

The sample intake summary on next page is from a treatment program for adult women who are chemically dependent (see  Figure 2.3). To qualify for the residential program, applicants must have a child who is three years of age or less and has been exposed to drugs. The day program is available to mothers who have a child older than three years. The applicant whose intake is summarized in  Figure 2.2 is applying to the residential program, which lasts one year. During this time children live with their parent in one of 10 agency apartments. To graduate from the program, the client must be employed or enrolled in school and be free of substance abuse. Some individuals enter the program voluntarily, and others are ordered to come as part of their probation. On admission, a staff member conducts a 30-minute interview, which is written up and placed in the client’s file within two days. The client then receives an orientation to the program and is assigned a care coordinator in charge of that case. The care coordinator and the client then have a more extensive interview, lasting approximately 90 minutes.

Figure 2.3 Intake Summary

Staff Notes

Staff notes , sometimes called  case notes , are written at the time of each visit, contact, or interaction that any helping professional has with a client. Staff notes usually appear in a client’s file in chronological order. They are important for a number of reasons:

· ■  Confirming a specific service : The helper wrote, “John missed work 10 of 15 days this month. He reported that he could not get out of bed. I referred him to our agency physician for a medication review.”

· ■  Connecting a service to a key issue : The helper may write, “I observed the client’s interactions with peers during lunch,” or “I questioned the client about his role in the fight this morning.”

· ■  Recording the client’s response : “Mrs. Jones avoided eye contact when asked about her relationship with her family,” “Janis enthusiastically received the staff’s recommendation for job training,” or “Joe resisted the suggestion that perhaps he could make a difference.”

· ■  Describing client status : Case notes that describe client status use adjectives and observable behaviors: “Jim worked at the sorting task for 15 minutes without talking,” and “Joe’s parents were on time for the appointment and openly expressed their feelings about his latest arrest by saying they were angry.”

· ■  Providing direction for ongoing treatment : Documenting what has occurred or how a client has reacted to something can give direction to any treatment. “During our session today, Mrs. Jones said she felt angry and guilty about her husband’s illness in addition to the feelings of sadness she expressed at our last meeting. These feelings will be the focus of our next meeting.”

The format of case notes depends on the particular agency, but they are always important. For instance, one substance abuse treatment facility uses a copy of its form for each client every day. A helper on each of the three shifts checks the behavior observed and makes chronological case notes on the other side. These notes allow the professionals working with a client to stay up to date on treatment and progress and provide the means of monitoring the case.

There are a number of other case note models, such as data, assessment, and plan (DAT), functional outcomes reporting (FOR), and individual educational programs (Cameron & Turtle-Song,  2002 ). These are all variations of the original  SOAP  format, originally developed by Weed ( 1964 ). SOAP is an acronym for subjective, objective, assessment, and plan. Developed to improve the quality and continuity of client services by enhancing communication among professionals, SOAP supports the identification, prioritization, and tracking of client problems so they can receive attention in a timely fashion (Kettenbach,  1995 ).

Subjective and objective aspects are both parts of data collection. Subjective refers to information about the problem from the client’s perspective or that of other people: “reports difficulty getting along with her coworkers” or “mother complains about client losing control and striking younger sister.” The helper’s observations and external written materials make up the objective component that is written in quantifiable terms: “client seemed nervous, as evidenced by repeatedly shifting in chair, chewing nails, rocking, and looking down.” The assessment section combines both previous sections for interpretation or a summarization of the helper’s clinical thinking regarding the problem. This is often stated as a psychiatric diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders IV, Text Revision(DSM-IV-TR; American Psychiatric Association,  2000 ) (discussed in  Chapter Eight ). The last section of the SOAP notes is the plan, which generally includes both action and prognosis: “next appointment is 5/25/05 @ 10 P.M.; prognosis is good due to motivation for and interest in changing anger behavior. Client also referred to anger management group for weekly meetings.”

Another format for case notes is illustrated by the notes presented next, from a residential treatment facility for emotionally disturbed adolescents. These notes are in the file of a 15-year-old female client who is thought to have a borderline personality disorder. At this facility, a staff person from each shift is required to make a chart entry; the abbreviations DTCETC, and NTC refer to day, evening, and night treatment helpers. Any other staff member who has contact with the client during the day (such as the therapist, teacher, nurse, or recreation specialist) also writes a staff note. The word level refers to the number of privileges that a client (ct.) has. For example, a client at Level 1 has a bedtime of 9 P.M.; a client at Level 3 would go to bed at 10 P.M.

This residential treatment facility gives its staff members strict guidelines for charting and consistent abbreviations: ct. to mean client, cue to mean a warning, and C to signify a consequence. Also, there must be no blank lines or spaces in a case note, so the recorder puts in the line and signature at the end of each entry. Note also that no names of other clients or staff members appear in any entry. Notes such as these are routinely reviewed by the helper.

You will also note that the word appropriate appears often. In this facility, it is an important word because these clients often behave and interact inappropriately. It is common for them to act out sexually, exhibit interpersonal difficulties, and rebel against any rules or authority figures.

CHAPTER SUMMARY

The assessment phase of the helping process includes the initial contact with the individual or individuals who need or desire services, the intake interview to gather data, and the documentation that is required. Evaluating the application for services concludes the phase.

Applicants learn about services in different ways, which often result in a referral. The first step in determining eligibility for services is the intake interview, which may be structured or unstructured. The intake interview is an opportunity to establish rapport, explore the needs or problems, identify client strengths, and give some structure to the relationship.

Case assignment follows acceptance for services and may occur in one of three ways. First, the helper who conducts the intake interview may be assigned the case. Second, the case may be assigned to a specialized worker who may provide either complex services (level specialization) or specific services (task specialization). Finally, a team of professionals may be responsible for a number of clients.

Documentation and report writing are important parts of the assessment phase. Two different types of documentation are process and summary recording. Intake summaries and case notes are examples of the documentation that occurs in this phase.

CHAPTER REVIEW

Now it’s your turn to practice the concepts introduced in  Chapter Two . You can review the key terms and answer the following questions.

KEY TERMS

Applicant

Assessment

Case or staff notes

Client

Confidentiality

Intake interview

Intake summary

Interview

Mental status examination

Privileged communication

Process recording

SOAP

Staff or case notes

Structured interview

Summary recording

Unstructured interview

REVIEWING THE CHAPTER

1.

How does a person’s previous experience with human service agencies influence his or her decision to seek help?

2.

In what different ways do people learn about available services?

3.

Distinguish between the terms applicant and client.

4.

What purposes does the interview serve?

5.

Describe the roles of the helper and the applicant during the initial meeting.

6.

Discuss different ways to define interview.

7.

What is the difference between interviewing and counseling?

8.

List the three factors common to all interviews.

9.

Describe what takes place in each of the three parts of an interview.

10.

Give three examples of issues that applicants may raise during the initial interview.

11.

Explain why intake interviews and mental status examinations are structured interviews.

12.

What does a helper need to know about confidentiality in the assessment phase?

13.

Discuss the two problem areas related to confidentiality.

14.

What questions guide the assessment of the information gathered during this first phase of the helping process?

15.

Describe case assignment.

16.

Compare process recording and summary recording, and provide an example of each.

17.

What purposes do staff notes (case notes) serve?

18.

Describe the SOAP format and its components.

QUESTIONS FOR DISCUSSION

1.

Why do you think the interview is an important part of the helping process?

2.

What evidence can you give that a good assessment is vital to the helping process?

3.

Speculate on what could happen if a client’s confidentiality was violated.

4.

Develop a plan to interview a client who has applied for public housing.

REFERENCES

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision). Washington, DC: Author.

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development80, 286–292.

Corey, G., Corey, M. S., & Callanan, P. (2007). Issues and ethics in the helping professions (6th ed.). Pacific Grove, CA: Brooks/Cole.

Enelow, A., & Wexler, M. (1966). Psychiatry in the practice of medicine. New York: Oxford Press.

Hutchins, D. E., & Cole Vaught, C. (1997). Helping relationships and strategies (3rd ed.). Pacific Grove, CA: Brooks/Cole.

Ivey, A. E., Ivey, M. B., & Zalaquett, C. P. (2010). Intentional interviewing and counseling: Facilitating client development in a multicultural society (7th ed.). Pacific Grove, CA: Brooks/Cole.

Kanel, K. (2007). A guide to crisis intervention (3rd ed.). Pacific Grove, CA: Brooks/Cole.

Kettenbach, G. (1995). Writing SOAP notes. Philadelphia: Davis.

McQuaide, S., & Ehrenreich, J. H. (1997). Assessing client strengths. Families in society78(2), 201–212.

Okun, B. F., & Kantrowitz, R. E. (2008). Effective helping: Interviewing and counseling techniques (7th ed.). Pacific Grove, CA: Brooks/Cole.

U.S. Department of Health and Human Services (n.d.) HIPAA. Retrieved from http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html .

Weed. L. L. (1964). Medical records, patient care and medical education. Irish Journal of Medical Education, 6, 271–282.

Weinrach, S. G. (1987). The preparation and use of guidelines for the education of clients about the therapeutic process. Psychotherapy in Private Practice5(4), 71–83.

CHAPTER THREE Assessment Skills

Now it’s your turn! The assessment phase of the helping process includes a number of important skills that will help you obtain the information you need to move through it. This information will provide the foundation for its other phases. In fact, taking the time to thoroughly assess the applicant, the situation, and the needed services contributes to a more effective and efficient experience for all participants.

Exercise 1: The Initial Interview—The Applicant’s Perspective

Helpees have a lot to teach us about the helping process. The following accounts relate the experiences of three helpees as they describe their initial interview.

Client I

I made a (self-referral) telephone appointment to talk with a professional who briefly advised me to bring documentation of current earnings, my most recent tax return, a current rent receipt and telephone bill, a copy of my separation or divorce decree, and a current bank statement (and other records, ad infinitum) with me to our meeting. The site of our meeting was a day-care center located near several housing projects and homes. This center helps families find in-home child care for residents from all parts of the city. When I arrived for my early morning appointment, the receptionist asked me to take a seat. After waiting one half-hour beyond my scheduled appointment time, the receptionist called my name and escorted me to the office of the professional who would interview me.

She was sitting behind her desk talking on the phone and motioned for me to take a seat. I again waited at length while she completed her telephone conversation. At that point, she acknowledged me with a rather perfunctory, “Sorry to keep you waiting. It’s been a crazy morning. Have any problem finding us? Good. Let’s get started. Did you bring all the documentation that we’ll need? Let’s see what we have here”—all in one breath. The desk that separated us served as a physical barrier to any feelings of warmth, caring, interest, acceptance, or respect, which I would have welcomed. In fact, I remember feeling that she was contemptuous of me; but I wonder, in retrospect, whether my own distaste at having to ask for assistance or respect influenced my perceptions. My interviewer immediately delved into evaluating and processing reams of application paperwork. She was not interested in any other aspect of my life. She never asked if I needed any other help, financial or otherwise. She didn’t offer information on any other resources that might have been available to me. In fact, she rarely made eye contact, but remained detached and businesslike. The experience felt much more like an interrogation than an interview. She fired questions at me, as she demanded each document that I was required to bring with me: “How much money do you receive from the child’s father each week? Why don’t you want to place your child in our day-care program instead of the satellite program? You indicated that you don’t own a car—if it’s that inconvenient for you to get here, how did you get here today?”

At the conclusion of our meeting, she explained the accounting procedures, indicating that I would pay the agency directly for services rendered by a satellite caregiver. Payment would be based on a sliding scale based upon my income and ability to pay. She then dismissed me, never getting up from her desk, as she advised me that I would hear from her just as soon as my application was reviewed for acceptance by her supervisor. In fact, I did not here from her at all but received a phone call from the day-care center.

1.

List what you learned NOT to do in the initial interview.

2.

Rewrite each negative you listed in Item 1 as a positive statement that will guide your behavior as a helping professional in the initial interview.

Client II

I don’t think anyone ever told me exactly what their job was. See, I was very subservient to anybody in that area because I was scared. I mean literally scared to death. I had a phobia of failing and having everything jerked out from under me.

Here’s what I think a helper should do. Clients are not numbers, so they shouldn’t be treated like Client Number 4622 or a Social Security number. When you tell a client that the appointment is at 3:00 P.M., then the appointment is at 3:00 P.M. Nothing should interfere with that. I am going to treat my clients that way.

I think clients are already intimidated before they ever come in. They have a feeling that the help could be taken away at any time. That is something else every caseworker should do, reassure the client that as long as they fulfill their obligations, they can’t lose the help they are getting. That was one of my biggest fears, and I was so afraid of it, I would not even ask. I would not even bring the subject up.

3.

List what you learned NOT to do in the initial interview.

4.

Rewrite each negative you listed in Item 3 as a positive statement that will guide your behavior as a helping professional in the initial interview.

Client III

The very first time I went to a meeting at DHS was to get help for myself, my daughter, and my ex-husband. When I went back the second time to apply for assistance for myself and my daughter, I ended up getting a really wonderful worker. I was walking on eggshells and I didn’t know where to go. I didn’t know what to do. I had no self-esteem, no self-respect. I was in the gutter and I didn’t know where to go. And didn’t know which end was up. My worker helped me.

I had another worker though who was awful. I had already started school and my worker changed. I went to this other worker, and she made me feel like dirt: “Here you are getting benefits, and you are not doing anything to help yourself. You are not even trying to find a job.” It was just like I was a nobody. She didn’t give me anything, and here I was doing everything I could. Her view was, I was on welfare, and I was a welfare mother, and that was all I was ever likely to be. In fact, I did go to her supervisor over that because it did hurt. And by that point I was strong enough to really voice how I felt. Had I had her in the beginning, I don’t think I would have been able to do anything about it, but later on when I gained the confidence through going back to school and through support group meetings, and counseling, I was able to see that what she was doing wasn’t fair to me. In fact, she ended up being taken off case management in DHS.

5.

List what you learned NOT to do in the initial interview.

6.

Rewrite each negative you listed in Item 5 as a positive statement that will guide your behavior as a helping professional in the initial interview.

Exercise 2: The Initial Interview Summary

One purpose of the intake interview is to assess an individual’s eligibility for services. The intake interview form in this exercise has information that was gathered during an interview at a mental health facility. A case manager interviewed a person who was referred by professionals at the hospital. Eligibility for services is determined by matching needs with services. The treatment team that will review the intake information includes a social worker, the intake case manager, a nurse, a physician, and the director of psychiatric services. Before the treatment team meets to determine eligibility, each member will read an intake summary prepared by the case manager.

You are charged with preparing the written intake interview summary. At this facility the summary is organized around the following items:

· ■ Worker’s name, date of contact, date of summary

· ■ Applicant’s demographic data: for example, name, address, phone number, agency applicant, Social Security number

· ■ Source of information during the intake interview

· ■ Presenting problem and client strengths

· ■ Summary of background and social history related to the problem

· ■ Previous contact with agency

· ■ Diagnosis summary statement

· ■ Treatment recommendations

1.

Read the intake interview form carefully. If some of the abbreviations are unfamiliar to you, see the legend at the end of the form.

Legend: Abbreviations used in form:

ct client
M mother
SF stepfather
N/A not applicable
c with
tx treatment
DC discharge

2.

Using the organizational headings listed at the beginning of Exercise 2, write an intake summary based on the information provided on the intake form you just read.

3.

What difficulties did you encounter in “putting the pieces of the puzzle” together?

4.

Did you need more information to write the summary? What additional information would you like to have had?

5.

Are you confident of your recommendations? What is the basis for your confidence or lack of confidence?

Exercise 3: Careful Assessment

The following case studies are about Susanna, James, Samantha, Alicia, and Montford, all homeless children attending school. The principal of the school has asked you to conduct an assessment of these children and provide initial recommendations.

Before you begin this exercise, go to the website that accompanies this book:  www.wadsworth.com/counseling/mcclam  Chapter Three , Link 1, to read more about homeless families and children.

Susanna

Susanna is 15 years old. The city where she lives has four schools: two elementary, one middle, and one high school. There are about 1,500 students enrolled in the city/county school district and about 450 in the local high school that Susanna is attending. For the past six months, Susanna has been living with her boyfriend and his parents. Prior to this, she left her mother’s home and lived on the streets. She is pregnant and her boyfriend’s parents want her to move out of their home. Her father lives in a town with his girlfriend, about 50 miles from the city. Her mother lives outside the city with Susanna’s baby brother. Right now Susanna’s mother is receiving child support for the two children. Susanna wants to have a portion of the child support so that she can find a place of her own to live. Her mother says that the only way that Susanna can have access to that money is to move back home. Susanna refuses to move back in with her mother.

You receive a call from the behavior specialist at Susanna’s high school. Susanna’s mother is at the school demanding that Susanna be withdrawn from school. Susanna’s mother indicates that Susanna will be moving in with her and will be enrolling in another school district.

Currently Susanna is not doing very well in school. She misses school and she tells the helper it is because she is tired and that she does not have good food to eat. She has not told the helper that she is looking for a place to live. Right now she is failing two of her classes and she has one B and two Ds. Her boyfriend has missed a lot of school, too.

James and Samantha

James is 10 years old and he has a sister, Samantha, who is 8. At the beginning of the school year, both of the children were attending Boone Elementary School. Both children live with their aunt and uncle; their parents are in prison. In the middle of the school year, the aunt picked up the children one afternoon and told them that they were going to move that evening. They picked up their clothes and a few toys and moved into a shelter. They didn’t know that this was a shelter for women and children who were being abused. The children were brokenhearted to leave their school. They had good friends there; James was head of the safety patrol and was the star of the choir and drama club. Samantha played with her best friend Carrie every day and all of her friends called her the “teacher’s pet.” Samantha says that she understands why she needs to go to another school, but James is angry that he has to transfer. The staff at the shelter tried to work out transportation back to the school but school officials told James and Samantha’s aunt that the children could not transfer back into the old district. James and Samantha are referred to the school behavioral specialist.

Alicia and Montford

About a year ago, Alicia and Montford, ages 6 and 7, moved into the New Horizon homeless shelter for families. They have been living there with their mom and dad for the past six months. The family may only stay at the shelter until the end of the month. The assistant principal at the local elementary school just called you to ask for assistance. Both Alicia and Montford are not performing very well in school and they are constantly fighting with their classmates and with their teachers. Neither of the children can read at grade level. Both have low math scores, and they have limited social skills. For example, yesterday Montford hit a kindergarten girl because she broke in line in front of him. He told his teacher to “go to hell” when she took him to the principal’s office. He never completes his work and never brings his homework to school. If the teacher sends a report home for his mom and dad to sign, he does not return the form.

Alicia tries to fade into the background at school, and she is equally unresponsive. She will not talk in class to her classmates or to her teacher. She just sits in the classroom and stares or puts her head on her desk. At recess she sits in the corner by herself. If she is made to play with the other children, she cries and runs off.

Because the state tests begin in the next month, the teacher and the principal are concerned about Alicia’s and Montford’s scores. The school has been on probation because of the regulations from the No Child Left Behind Act. Every score is important to the school administration. You, as the mental health services coordinator, have been called to talk with the parents about motivating these two children.

1.

Describe your reactions to each of these students. Discuss their parents and the relationship they have with them.

Susanna: __________________________________________________________________

James and Samantha: _______________________________________________________

Alicia and Montford: _______________________________________________________

2.

Sometimes we write about our clients using subjective language instead of objective language. Making interpretations, failing to indicate the sources of our information, and labeling represent challenges to objective writing. Review the information you provided about Susanna, James, Samantha, Alicia, and Montford and use the following items to evaluate your objectivity.

Interpretation

List phrases that go beyond factual information. Rewrite in terms of evidence and not your own opinion.

·  Phrase 1: Beyond factual information

·  Rewrite phrase 1

·  Phrase 2: Beyond factual information

·  Rewrite phrase 2

·  Phrase 3: Beyond factual information

·  Rewrite phrase 3

Citing Direct and Indirect Observation

Look for phrases that do not indicate the source of the information presented. Indicate if the information does not come from your own observation.

·  Phrase 1: No indication of source

·  Rewrite phrase 1

·  Phrase 2: No indication of source

·  Rewrite phrase 2

Using Labels

Sometimes it is easier to write about clients using labels that you believe communicate information about the client. Labels may be negative or positive. Look at your descriptions and indicate where you used labels to describe the client or the client’s situation.

·  Phrase 1: Indicate where labels are used

·

·  Rewrite phrase 1

·  Phrase 2: Indicate where labels are used

·  Rewrite phrase 2

Exercise 4: Case Notes

Case or staff notes are a type of documentation, discussed in  Chapter Two , that provides a written record of each interaction between a helper and an applicant or client. Although the format for case notes varies from setting to setting, they are always an important part of the case file.

A beginning helper who has six different clients wrote the following case notes. Critique each case note. What is helpful about the information? What questions does each case note raise?

· ■ 4-1-XX Client seemed in a hurry. We talked briefly about how she is dealing with her stress. Client says she is getting overwhelmed by all her responsibilities but is getting through them. She also mentioned her excitement about this weekend.

· ■ 2-24-XX Worker observed client taking Strong Inventory Test. Worker was not there.

· ■ 3-3-XX 2:25 P.M. Said she is okay.

· ■ 3-5-XX 3:15 P.M. Said she was well and laughed.

· ■ 3-8-XX 2:00 P.M. Not home, left message.

· ■ 11:15 P.M. Phone was busy.

· ■ 11:30 P.M. Phone still busy.

· ■ 6-15-XX 3:30 P.M. Client stated that he was doing well, he had a “fun weekend,” and identified no new problems at this time.

· ■ 4-1-XX I tried to contact client Sue Jones by phone today between 8:30 P.M. and 9:00 P.M. I called four times but line was always busy. Everything should be going well.

· ■ 9-10-XX I called Janie to find out why she missed our appointment. She stated she forgot. She is working a lot.

Exercise 5: First Impressions

The intake interview is a starting point to provide help. During a successful intake interview, the helper establishes rapport with the client by demonstrating respect, empathy, and cultural sensitivity. The helper who conducts the intake interview also presents a positive environment that ensures confidentiality, eliminates physical barriers, and promotes dialogue. Cultural insensitivity on the helper’s part may convey attitudes of sexism, racism, ethnocentrism, and/or ageism. These may occur when the helper makes unwarranted assumptions about the client based upon the helper’s stereotypes of that population. In the following clips on the Wadsworth website, www.cengagebrain.com/shop/ISBN/1111298432 < http://www.cengagebrain.com/shop/ISBN/1111298432 >, three individuals relate situations where they experienced cultural insensitivity or discrimination.

Phil describes an appointment for a hearing screening.

1.

Describe the problem Phil experienced.

2.

How did Phil feel about this experience?

3.

How would these feelings help or hamper the helping relationship?

Nicole shares a family experience buying a car.

1.

Describe the problem Nicole experienced.

2.

What is the goal of the car salesperson?

3.

How did Nicole feel about the experience?

4.

How would her feelings help or hamper the process of closing the deal on a car?

Tracey recounts an interview for a job.

1.

Describe the problem Tracey experienced.

2.

Explain the two assumptions that the interviewer made about Tracey.

3.

How did she react to these assumptions?

4.

How did Tracey feel about the interview and the interviewer?

Conclusions

1.

What do these experiences have in common?

2.

What have you learned from the experiences of Phil, Nicole, and Tracey?

Exercise 6: Using the Strengths-Based Approach

Think about a change you would like to make. Identify the problem that you would like to address and complete the form ( Figure 3.1 ) that follows.

Figure 3.1 Strengths Identification Form

2.

Review the description of motivational interviewing. How would you apply motivational interviewing to the problem you identified in Question 1?

Exercise 7: Strengths-Based Approach to a Case Study

The following case introduces Joe, a homeless male. A brief case summary describes his current status and  Figure 3.2  represents a strengths-based assessment of Joe. 1

Service Plan: Homeless Adult

Homeless Joe, a 55-year-old male, SS# 555-55-5555, Axis I: Schizophrenia, Paranoid, 295.30; Alcohol Abuse, 305.0; Axis II: deferred, 799.9; Axis III: Anemia; Axis IV: problems with social environment, occupational problems, housing problems, economic problems, other psychosocial and environmental problems; Axis V: Global Assessment of Functioning (GAF) at time of admission to case management services (CM), 40. Joe is a Vietnam veteran. While in the military, he was a radio operator, then a paramedic on the front line. He was honorably discharged in 1969. He completed two years of college before being drafted. He grew up in a small, lower-income community outside a larger town. He has an older brother, but has little to no contact. A social worker (SW) at the regional mental health facility had seen Joe in the neighborhood where she lives, walking to and from town for many months. A year ago, the SW saw Joe walking home in the snow late one night and gave him a ride. She gave him a ride several times after that. At that time Joe was working nights at a dialysis clinic. Several months later, the SW saw Joe almost daily sitting in a field in the neighborhood. Some mornings it was evident Joe had spent the night sleeping in the field. The SW had often seen Joe purchase beer and snack food in the grocery. Joe had been arrested several times in the winter for intoxication. Recently the SW saw Joe living in a tent at the end of a dead-end street behind the grocery store. He usually appeared clean and in neat clothes but occasionally was wet and dirty. Attempts to talk with Joe indicated he was experiencing visual and auditory hallucinations and was very paranoid about his environment. He was guarded and anxious when engaged in conversation. He did state he occasionally worked mowing and doing yard work for a man who lives near his “tent house.” Joe indicated he liked living outdoors and did not like confined settings. Joe was admitted to the regional mental health hospital in January, intoxicated and responding to internal stimuli. While in the hospital, he was referred for CM services. At the initial interview, he refused CM services. The SW, who had met Joe in the community, became aware of Joe’s reluctance and, with the CM, visited Joe twice a week during his inpatient stay. When he was ready for discharge, he had agreed to CM services, but he was fearful of coming into the clinic for medication. He discharged on a ×1 month Haldol Dec (one month’s dosage). He has met with his CM at his tent three times. They have talked about Joe’s mental illness, his history, and what he would like to work on with the CM. It does not appear that Joe has had any prior mental health services, except for brief stays in the Veterans’ hospital in 1970, 1989, and 1995. He has not taken any medication, other than while in the hospital. He drinks beer “when the voices are too loud.” He has lived transiently, except for brief stays with family or in missions in three different states. His only income is from doing yard work and odd jobs when he can get them. He says he is tired of moving around and wants to stay in his home community. Today, the CM wants to talk with Joe about his service plan.

Figure 3.2 The Strengths/Resources Assessment in the Seven Domains “Homeless Joe”

1.

You are meeting with Joe to talk about a plan. How might you focus on strengths to engage Joe in the helping process?

2.

Describe how you would use motivational interviewing to help Joe change his present situation.

3.

By focusing on Joe’s strengths, what would you hope to accomplish in each of the three helping phases?

Assessment

Planning

Implementation

4.

What additional information would you like to have about Joe that would facilitate a strengths-based approach?

5.

What resources do you think are available for Joe? How would you find out?

In More Depth: Forming Impressions of Others

Chapter Two  explores assessing the client, documenting the intake interview, and writing case notes. Characteristics of quality assessment and well-written documentation include objectivity and clarity. At times, the basic assumptions that helpers make about their clients prevent them from making objective assessments or writing balanced or factual case notes. When helpers make assumptions about their clients, they may have formed impressions of them without proof or factual information.

So how do we form this subjective impression of others? Let’s look at four concepts that social psychology deems important in assessing others: (a) the sources of information, (b) snap and systematic judgments, (c) attributions, and (d) cognitive distortions (Weiten, Lloyd, Dunn, & Hammer,  2009 ).

Sources of Information

Every day we are bombarded with sensory input about the people we encounter. To manage this quantity of data, which determines how we react, we use various sources and types of information to categorize the data and form impressions of others. Many times this categorization occurs very quickly, and often we do not even know that we are forming impressions (Williams, n.d.). We believe that we are seeing people as they really are. The sources of impression formation include appearance, verbal behavior, actions, nonverbal messages, and information about situations. For example, you are meeting a client for the first time in the client’s home. A scantily clad woman with vivid makeup and bleached blonde hair (appearance) opens the door. She says, “Who are you? What do you want?” (verbal). You see her holding a small child very tightly in her arms; she is frowning at the child (nonverbal). Before you have a chance to answer, she slams the door in your face (action). This is a home visit and the client’s name is on the mailbox by the door; you are investigating an alleged child abuse reported by the next-door neighbor (situation). In this example, each of the sources of data exists; appearance, verbal and nonverbal messages, and actions add information about the situation. What type of impression did you form of this woman?

Let’s look at how we form snap and systematic judgments as we meet individuals for the first time and then as we encounter these individuals again.

Snap and Systematic Judgments

As we form impressions of others, we use snap judgments to record our first impressions. Unless there is a strong motivation to go beyond these first impressions, we often retain them (Sherman, Stroessner, Conrey, & Omar,  2005 ). Because each of us has so much information to process, we become “cognitive misers.” This means that we depend upon automatic processing to summarize and make judgments of others. With automatic processing, we make impressions quickly; these impressions come from many of our previous experiences of other people.

There is another way to process this information by using controlled processing, or taking your time to identify your first impressions and consciously moving beyond them (Neuberg & Fiske,  1987 ). Controlled processing is time-consuming and difficult. It includes thinking about whether the categories and opinions you are using to make judgments about others are accurate. It is easy if the information you receive fits your traditional way of thinking. But if the information challenges your first impressions, then you have to gather additional information and come up with new categories. This is hard work.

Without this type of intentional reflection, individuals take their quick opinions and begin to make systematic judgments of others. Think about your first impressions of the woman at the door described in the preceding section.

· ■ Describe her in three words.

· ■ What was her reaction to you?

· ■ Why did she react as she did?

· ■ What was her relationship to the child?

· ■ Why was she holding the child so tightly?

If you can generate more than one answer to each of these questions, it is easier to move beyond initial assumptions and determine what information you need to understand this woman at a deeper level.

Another way in which we form impressions of others is using attribution or ascribing causes for an individual’s behavior or situation. We use attribution to make assumptions of why individuals behave the way they do.

Attributions

When we make attributions, we assume we know the causes of another’s behavior. These attributions contribute to how we form impressions of others. Sometimes we believe that individuals are responsible for their own behavior. Other times we believe individuals are victims of their environments (Adams & Betz,  1993 ). For example, as you think about the scantily clad woman described earlier, do you believe that her dress is her own responsibility? Or did another individual or a social norm “cause” her to dress in that fashion? If you believe that she is responsible for her dress, then you ascribe internal attribution, believing that she chooses to dress and act the way she does because of her personality, characteristics, or abilities. If you believe she is responsible for herself, then you think she must accept the consequences for her actions. If you believe that her dress and behavior is not only her personal responsibility, but that she also is under social pressure to dress and act in a certain way, then you ascribe external attribution. In other words, the responsibility for her action and behavior does not just rest with her, but also with society.

The “fundamental attribution error” (Gilbert & Malone,  1995 ) occurs when we tend to explain the behavior of others using personal rather than situational or contextual causes, without knowing the facts. In other words, behavior is a choice of the individual and is influenced by personal characteristics such as temperament, personality, traits, values, and interests. A description of the woman who slammed the door, based upon the fundamental attribution error, might include many of the following comments:

·  Boy, is she dressing to get attention. She must have a need to be noticed and must be trying to dress provocatively to gain the attention of the men she encounters. The way that she slammed the door means that she knows exactly who I am and why I am here. She does not want me to come in and question her about her behavior to her child. She was holding the child too tightly and she looks like she was trying to hurt the child.

This account takes into consideration situational factors that might or might not explain the reasons for her behavior. Correct or incorrect assumptions might explain the reasons she is dressing as she is, call into question her knowledge of the helper’s visit, include the effects of any previous visits she has had from strangers or what happened in the house before she heard the knock on the door, or provide other reasons for her holding the child tightly.

Ascribing reasons for behaviors or circumstances without information is likely to cause errors in how we form impressions of others. Cognitive distortion is another way in which we may form erroneous impressions.

Cognitive Distortions

As stated earlier, many times we process information about others quickly; we often lack the motivation to pay attention to details and to question what these details mean. Cognitive distortions occur when we choose an easy way to define others by using social categorization and stereotyping. Social categorization occurs when we define others as “them” or “us.” By categorizing according to nationality, race, ethnicity, religion, age, gender, sexual orientation, and other groups, we quickly assign characteristics to individuals in those groups. And, if it looks like an individual is not in our group, then he or she immediately falls into the group of “the other.” In other words, those who are not similar to us become part of the “out” group. Members of our “in” group have very positive characteristics and are viewed in a favorable light. Th ose in the “out” group are different and have more negative characteristics. Let’s return to the woman answering the door. In what ways does she belong to “your” group or groups? In what ways is she different? Would you consider her to be part of the “out” group or the “in” group? Why?

Stereotyping is another way we create cognitive distortions. When we stereotype others, we immediately ascribe characteristics just because they belong to a certain group. Phrases such as “all women,” “most men,” “Catholics are” and “Hispanics always” denote stereotyping. Many stereotypic beliefs that we hold are not obvious to us. In fact, we confuse stereotypes with facts. How do we know when we are using stereotypic or factual thinking? One signal occurs when we are surprised by the behavior of others. When was the last time you were pleasantly surprised when an elderly man or woman competed and won a physically based sporting event or someone with a serous mental illness was able to maintain stable employment? The surprise you felt indicates that the individual violated the norms or stereotypes that you have for a particular group.

Now that you are more familiar with different ways that you form impressions of others and are aware of barriers to that process, let us examine how this knowledge helps you as a helper engage in assessment and report documenting.

Exercise 8: Bridget—Is She “In” or “Out”?

CASE STUDY: BRIDGET, PART 1

Bridget is 22 years old and a drug addict. Her parents were divorced in her early teens. She changed high schools three times. Her father is an alcoholic and her mother is clinically depressed. She has been in jail nine times and she has been in and out of hospitals for the past five years with various illnesses. Her boyfriend physically abuses her. For the past three years, Bridget has been involved in illegal activities to get money for drugs or to get drugs. Right now she is a convicted felon, and she could receive a sentence of six months in the penitentiary or six months on probation. She wrote bad checks and was caught with drug paraphernalia. Bridget has just found out that she is pregnant with a girl. She does not know who the father is.

Bridget has a brother and two sisters. She grew up in a suburban neighborhood. In her early teens, her dad admitted that he was an alcoholic. He left home to “get some help” but never came back. He divorced Bridget’s mother two years later. The family had to move out of the neighborhood into a smaller house. They had to move again to a house that charged less rent. Changing schools with each move, Bridget began to use drugs to help her belong to an “in” crowd.

1.

What are your first quick impressions of Bridget?

2.

Why do you think you made those first quick impressions?

CASE STUDY: BRIDGET, PART 2

Bridget moved out of her mother’s house during her senior year and moved in with her father. Bridget’s father was dating every night and he knew only a little about what Bridget was doing. She was using drugs daily, including marijuana, cocaine, and crystal meth—and she was now living with her boyfriend. Bridget worked at a local grocery store. Her boyfriend was selling and using drugs. Bridget attended school sporadically. She graduated and passed the local and state tests. After graduation, she continued living with her boyfriend. Her work record was irregular and she kept changing jobs. At the age of 20, Bridget and her boyfriend traveled to Mexico to buy drugs. Their plan was to buy the drugs and then sell them in the United States. Bridget made the trip to Mexico successfully. But on the return trip, she was stopped by the police just after she crossed the border. She was jailed for possession. She called her family, but they decided that they would leave her in jail for one night. Bridget was released on bail. Her boyfriend was already out of jail on bail. They found their car and unloaded the drugs that the police did not find. She was arrested soon after that, but she had a false I.D. The police ran the I.D., discovered who she was, and then arrested her again.

1.

What are your more systematic judgments of Bridget?

2.

How have these changed from your first impressions? Why do you think that these impressions changed?

CASE STUDY: BRIDGET, PART 3

Bridget stayed out of jail for three months. She was then arrested for prostitution. This time she spent almost four months in jail. She was placed on probation and lived in a halfway house. During that time she received a chip from Alcoholics Anonymous for 100 days of sobriety. Bridget decided that she would move back home, so she began to live with her mother. She got a job, paid rent to her mother, and then moved into her apartment. She took her boyfriend back. Before long, she began using drugs again. Her boyfriend continued his physical abuse. She lost her job for irregular attendance and spent her money on drugs. That summer Bridget was hospitalized with pneumonia. Her physical health had deteriorated. She weighed only 90 pounds, and she had lost most of her hair and some of her teeth. While she was in the hospital many of her family came to visit. They all wanted to help her. Bridget refused. All that she could think about was going back to her boyfriend and the drugs.

1.

Do you think that Bridget is responsible for her situation (internal attribution) or is her environment responsible? Explain the rationale for your answer.

2.

How might the “fundamental attribution error” apply to your thoughts about Bridget?

CASE STUDY: BRIDGET, PART 4

Once Bridget was out of the hospital, she moved in with two friends. Her boyfriend joined her there. She continued to use drugs. She stole checks, food, and medicine. Bridget sold the drugs that she didn’t use. She was arrested again. In the jail, she tried to commit suicide. The police took her to the hospital. She was placed on suicide watch. During a routine physical exam, Bridget found out that she was pregnant. She waited for three months for a court date. She was placed in rehabilitation for six months and on probation for three years. It is clear that if she violates the law again, she will go to prison.

Currently, Bridget is four months pregnant and has no idea who the father of her child is. She is in rehabilitation. Her mother comes to visit her. Right now she is clean.

1.

To which social categories does Bridget belong? To which social categories do you belong?

2.

In what ways is Bridget in your “in” group and your “out” group? How does this influence your impressions of her and how would this influence your initial assessment of her?

3.

Did you or could you stereotype Bridget after reading the first two paragraphs? Describe the stereotype. After knowing a more complete story, does the stereotype remain?

SELF-ASSESSMENT

1.

Write your explanation of confidentiality that you would provide to an interviewee.

2.

Your goal in the initial interview is to obtain information. Would you be more comfortable conducting a structured interview or an unstructured interview? Why?

3.

What would be your biggest challenge in fulfilling the report writing and documentation responsibility?

REFERENCES

Adams, E. M., & Betz, N. E. (1993). Gender differences in counselor attitudes toward and attribution about incest. Journal of Counseling Psychology, 40, 210–216.

Gilbert, D. T., & Malone, P. S. (1995). The correspondence bias. Psychological Bulletin, 117, 21–38.

Homeless Education Program. (n.d.) Case study I: Homeless liaison networking session. Retrieved from http://www.utdanacenter.org/theo/downloads/he101/

Neuberg, S. L., & Fiske, S. T. (1987). Motivational influences on impressions formation:

Outcome dependency, accuracy-driven attention, and individuating processes. Journal of Personality and Social Psychology, 53, 431–444.

Sherman, J. W., Stroessner, S. J., Conrey, F. R., & Omar, A. (2005). Prejudice and stereotype maintenance processes: Attention, attribution, and individuation. Journal of Personality and Social Psychology, 89, 607–622.

Weiten, W., Lloyd, M. A., Dunn, D. S., & Hammer, E. Y. (2009). Psychology applied to modern life: Adjustment in the 21st century (9th ed.). Belmont, CA: Wadsworth.

Williams, R. (n.d.). Social perception/attribution. Retrieved from http://www.nd.edu/~rwilliams/xsoc530/attribution.htm.

1Source:  Material adapted from personal communication from Debby Lovin-Buuck, 2004.

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:

What is known about the source of the problem?

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

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

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

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.

 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?

 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, but MMY 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 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:

What is known about the source of the problem?

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

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

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

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.

 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?

 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, but MMY 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 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 EditionText 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 & Fitzpatri

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.

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, the rescue/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

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 TWELVE Implementation and Termination Skills

Implementing a plan for service delivery often involves two responsibilities. One is the provision of direct services; a second is the coordination of services by other staff, other agencies, or both. These responsibilities are introduced in Chapters Ten and Eleven. Both service provision and service coordination require the skills that are the focus of this chapter. Exercises related to making referrals, monitoring service delivery, working with other professionals, being an advocate, and terminating the helping relationship will enable you to practice these skills.

Exercise 1: Janis Jones

Client Janis Jones was introduced in  Chapter Nine . Here is her situation:

·  Janis Jones has just come to live with her grandmother in a small house in the community near the university. She is 12 years old and “runs with a rough crowd,” as her grandmother describes it. She and her mother have never really bonded but her mother retains legal custody so that she can cover Janis with her insurance. Janis talks back to her grandmother, disobeys her, and pays little attention to the rules. About two months ago, she screamed at her grandmother in the parking lot of a movie theater and was hysterical for two hours. Her mother and her grandmother believe she needs to see a helping professional and she has agreed. The helper thinks Janis is depressed and arranges for her to have medication. Unfortunately, her behavior continues to be out of control. She is becoming increasingly defiant, staying out late, and not telling her grandmother where she is going. Her grandmother thinks she may be experimenting with drugs. Slapping her grandmother and threatening to kill her is the latest incident. In  Chapter Nine  you identified Janis’ problems, encouraged her participation in plan development, and anticipated barriers to service delivery.

Goal 1 of the plan follows. Review it and respond to the questions that follow.

1.

How will you encourage Janis’ participation in reaching the goal?

2.

What services will you as the helper provide?

3.

Describe your role as a behavior changer.

4.

How will you work with Janis and her grandmother as a caregiver?

5.

How will you monitor service provision using your skills in writing goals and objectives? Write yourplan.

Goal: ________________________________________________________________

Objectives: ___________________________________________________________

6.

Describe the criteria you will use for the evaluation of service provision.

7.

Will you be a broker or a mobilizer or both? Explain.

8.

How will you make the referrals? Any barriers?

Exercise 2: Working with Other Professionals

To meet Goal 1, you as the helper will work with other professionals, including a psychologist (psychological evaluation); social worker (social history); physician (physical examination); principals, school counselors, and teachers (educational information); and other helping professionals.

1.

What will you tell them about Janis?

2.

What questions do you have for each professional to guide his or her evaluation of Janis or your data collection?

Psychologist: _________________________________________________________

Social Worker: _______________________________________________________

Physician: ___________________________________________________________

Principal: ____________________________________________________________

School Counselor: _____________________________________________________

Teachers: ___________________________________________________________

Exercise 3: Making a Referral

My name is Natasha. Today I am attending a local community college. I am 28, with four kids. My oldest is 12 and my youngest is six months. I am divorced from my first husband, the father of my first child. I live with my mom. She helps me take care of my kids so I can go to school. Going to school has been a life-long dream for me. I am convinced that, even in these tough economic times, I’ll be able to get a job. I’m studying human services and computer technology. My advisor tells me that the combination of the two areas of study will separate me from the rest of my peers.

Now that you know the good parts of my life, let me tell you why I need help and why I need it badly. My mom has been my main source of support all of my life and she is dying. Only three months ago she was diagnosed with a brain tumor. The doctors gave her six months to live. Before she left the hospital I talked with the hospital social worker. We have hospice care and there is someone who comes to bath her twice a week. A nurse comes three times a week. I think that she may die any day. She has been in the hospital for over 40 days; right now she is at home and I am trying to care for her. And now that she can’t take care of the kids, I am exhausted, can’t get my homework done, can’t get to class, and am short with the kids. I am not doing anything very well except taking care of mom. And she is beginning to need more help than I can give her. People from our church have helped from time to time bringing meals by.

One thing that my human service classes have taught me is that I need to be able to ask for help. That is why I am here today.

1.

Using the information provided by Natasha, list two problems that she is experiencing.

2.

Assume that your job as a helping professional is to provide Natasha the services she needs through referral. Also assume that Natasha lives in the city or town in which you currently reside. Using the telephone book, the web, and/or a directory of social services, identify a resource to meet Natasha’s needs for each problem you listed in Item 1. Find out the following information about the agency:

· a.What is the purpose of the agency?

· b.What services does the agency provide?

· c.What is the target population?

· d.What are the eligibility criteria to receive services?

· e.What process is available for making referrals?

Exercise 4: Monitoring Natasha’s Progress

Assume that you referred Natasha to the agency you investigated in Exercise 3.

1.

Write a summary of Natasha’s encounter with this agency from Natasha’s point of view. Use your readings and experiences to create this encounter.

2.

Based upon the summary of Natasha’s encounter, answer the following questions that will help you, as the helping professional, monitor the services Natasha is receiving.

Review of Services

· a.Is Natasha receiving services? What services is she receiving?

· b.Is Natasha satisfied with the services she is receiving and with her interaction with the helping professional agency’s staff?

Changing Conditions

· a.What change(s) has Natasha experienced? What change might she anticipate? Has her situation changed? How?

· b.Do the services she is receiving reflect the changing conditions? How?

Evaluating Progress

· a.Has the problem changed? How?

· b.Has there been any resolution to the problems?

· c.Should the case be closed? Why or why not?

In More Depth: Advocacy

Advocacy is speaking on behalf of others, pleading their cases or standing up for their rights. When helpers act as advocates for their clients, they are supporting, defending, or fighting for another person or group. Advocacy is also related to client empowerment and participation, as helpers support clients’ involvement in decisions about their own treatment and welfare. A caseworker at a family center in the Bronx describes a situation faced by AIDS patients that illustrates the need for advocacy:

·  Temporary housing is available for the families of clients with AIDS; however, if the client dies, then the family can no longer stay in that housing. This is particularly devastating to the children who are involved. It seems so unfair, and to my knowledge, no one is addressing this problem.

Advocacy is very important for helping professionals. Often, clients are unable to articulate what they need, nor do they understand what choices are available to them. They may not have the necessary information or the skills needed to present their positions. In some situations, what they desire is in direct conflict with people in authority. Clients may then be too intimidated to speak for themselves, or the people in power may refuse to consider client wishes. Terry is an example of such a client.

·  Terry is a 14-year-old who has just been diagnosed HIV-positive. She is terrified of her medical condition and will not talk to anyone about it. She just sits and stares when the caseworker, her mother, or any other member of her family tries to address the subject. Her mother wants to send her away to a residential school, but Terry will not speak of this or any related issue.

In some agencies, the people in charge may not wish to hear client complaints or grievances. There may be no way for clients to appeal decisions or discuss methods of treatment they do not support.

Clients, by definition, are not often in a position to act as advocates for themselves. Advocacy requires confidence, a feeling of control, and an understanding of the system. Most clients find themselves in the human service delivery system because they do not have these characteristics. One caseworker at a school for the deaf tells how she remained an advocate even after her official responsibilities were completed.

·  In this particular instance, we had made more than one report to Human Services, and Human Services was already involved, but then closed the case. Although our reports were not the reports that reopened the case, the case was reopened and the children were removed. . . . What is unique about this particular case is that usually when they are removed, I don’t have any further contact with the families . . . but I just knew that the kids were going to be returned, and I felt like I needed to maintain that relationship, because I would be making recommendations to the court for return.

The following are some common client problems that helping professionals may consider appropriate for advocacy:

· ■ Client has been denied services, or services have been limited.

· ■ Client has expressed interest in one method of treatment but has been given a different method.

· ■ Client’s family has made decisions for him or her.

· ■ Client has little information about the assessments gathered or the decisions made.

· ■ Client has been denied services based on factors such as race, gender, or religion.

· ■ Client has been given treatment contrary to his or her cultural norms.

· ■ Client has been treated with disrespect by human service professionals.

· ■ Client is caught in the middle of a conflict between two agencies or professionals.

· ■ Client is being given unsafe or indifferent care.

· ■ Client does not know what his or her rights are.

· ■ Rules and regulations do not serve the client’s needs.

Helping professionals are well positioned to provide advocacy for clients they serve. In the first place, they know their clients. They are the most familiar with their clients’ skills, values, wishes, and the treatment they have received. A measure of trust has been built between the client and the helper, so the helper is likely to hear from the client if there has been unfair treatment. Helping professionals are also in contact with family members, friends of the client, and other professionals with whom the client is involved. The helper therefore has immediate access to anyone who may be involved in unfair practice. Also, in the process of monitoring service delivery, the helping professional may discover situations that warrant advocacy.

Advocacy is not an easy role to perform. Before beginning an advocacy effort, there are several tasks to be completed. First, the helper must gather the facts of the situation and then determine whether there is a legitimate grievance—whether making requests on behalf of the client would be justified. Then the helper must determine whether advocacy is appropriate, rather than other methods such as problem resolution or conflict resolution. Third, the helper must discuss the need for advocacy with the client and show willingness to speak for the client. He or she must have the client’s approval before any advocacy takes place. Many helpers do not like conflict, and they fear that, as advocates, they will not be successful in meeting the needs of their clients. Advocacy is complicated because helpers have divided loyalties to the agency, the supervisor, and the client. Personal values and beliefs of the helping professional may complicate the advocacy process. The following guidelines support their work of effective advocacy. These guidelines build on the knowledge, skills, and values presented in our previous discussion of the assessment, planning, and implementation phases of the helping process.

KNOW THE ENVIRONMENT IN WHICH THE CONFLICT TAKES PLACE

This is important when planning how to act as an advocate for the client. It is helpful to know the appropriate person to whom to make the appeal. Having a good referral network and a good relationship with many agencies is useful in understanding the environment.

UNDERSTAND THE NEEDS OF THE CLIENT AND OF THE OTHER PARTIES INVOLVED

It is helpful if the advocate can understand why the other parties are in conflict with the client or seem not to respect the client’s wishes. If the advocate has this information before the appeal, strategies can be developed to meet some of the needs of all involved parties or, at the very least, articulate the common ground.

DEVELOP A CLEAR PLAN FOR THE CLIENT

The advocate needs to be clear about what the client needs and what the other parties must give or give up to meet those needs.

USE TECHNIQUES OF PERSUASION WHEN APPROPRIATE

Many situations are suited to persuasion—using the responsible model for advocacy. Persuasion is used to support client needs while respecting the rights of other parties as well. They include stating the problem clearly, presenting critical background information and facts, explaining why the situation needs to be changed, and detailing an acceptable solution.

ONCE THERE IS AGREEMENT, IT NEEDS TO BE STATED OR WRITTEN

All parties need to agree.

USE MORE ADVERSARIAL TECHNIQUES WHEN PERSUASION PROVES INEFFECTIVE

Using techniques that challenge the system directly, the helper makes a formal appeal or takes a case through legal channels in an effort to promote change on behalf of the client. In a grievance procedure or a legal challenge, the client has an opportunity to be heard, either verbally or in writing. Usually the client’s case is heard by an impartial person or group, and a ruling is made. Another adversarial technique is to use the media to take the client’s case to the public.

In the case of Terry, her mother wants a solution to the problem right away. She is determined to send Terry away and has already made contact with three residential programs. She plans to move Terry somewhere as soon as possible. In reality, Terry’s mother is frightened by what lies ahead for Terry and for the family. The only way she knows to cope is to distance herself from the problem. The caseworker feels strongly that Terry should have a voice in the decision; she begins her advocacy work by trying to talk with Terry about what she wants.

There does not necessarily need to be a special circumstance for the helping professional to assume the advocacy role. In the course of helping, there are many opportunities to act as an advocate for the client. The helper then integrates advocacy into other responsibilities. Each of the actions listed next represents basic goals and values of the helping process discussed in  Chapter One . These not only characterize effective advocacy but they are also good standards of practice.

· ■ Provide quality services by involving a team of professionals and the client (or, when appropriate, a member of his or her family).

· ■ Interact with the client to plan treatment that is congruent with his or her values and cultural orientation.

· ■ Monitor the case and set goals and outcomes based on quality standards of professional care.

· ■ Continually communicate with other professionals about issues that relate to client rights.

· ■ Plan treatment that takes into consideration the client’s preferences, strengths, and limitations, and provide additional support if you anticipate that he or she will have difficulty.

· ■ Speak for the client only when he or she gives permission.

· ■ Educate the client about the agency’s policies and procedures.

· ■ Create an environment that facilitates decision making by the client.

· ■ Educate the client about options in treatment and about the process of making the treatment plan, and discuss the barriers that may be encountered during the implementation phase.

· ■ Work within the system to support, modify, and create policies. Know which professionals are involved in this work and discuss your opinions with them. Volunteer for committees where policy issues are considered.

· ■ Become involved in the political process. Get in contact with public policymakers.

Advocacy work is difficult, and the helper must also exercise good judgment in choosing when to attack barriers to the client’s cause. At times, the need for advocacy may not be clear cut.

·  Martha Severn has just been asked by one of her clients not to report the $10 a week that she makes taking in laundry. Reporting this income would mean that the client will lose some of her scholarship aid for school. Instead, the client wants Martha to try to change the eligibility rule. Although changing the rule might seem a special favor for this particular client, Martha happens to believe that this policy is a good one.

In other instances the helper may have to deal with competing interests—those of the agency and fellow staff members, as well as the client’s.

·  James Dowling is a student intern at a mental hospital. He believes that one of his clients is being abused by a night technician. His client tells him of beatings during the night shift.

·  Ms. Wise is an elderly client who receives attendant care at home. The agency that coordinates Ms. Wise’s care has a policy of keeping clients on home services for as long as possible. Cheryl Santana, a helper at the agency, believes that clients remain much too long in home care. Cheryl makes recommendations for residential care, and the agency routinely rejects those recommendations.

Helpers must be aware of how their advocacy efforts are perceived by others. Many helpers believe that their first loyalty belongs with the institution. Others feel that they need to support the efforts of the team. Vigorous advocacy, at the expense of team camaraderie, may jeopardize the client’s trust in the team. Also, it is difficult to act as an advocate for certain clients. Some people are dishonest, greedy, or troublemakers. With such clients, the helper must think clearly about the legitimacy of any client demands and approach the issues with fairness in mind.

We have focused on advocacy at the client level. This means speaking on behalf of clients whether pleading their case or standing up for their rights. An example of the roles and responsibilities at this level is Stan.

·  The social worker met Stan at the hospital emergency room following treatment for a suicide attempt. Stan is a cross-dresser who is narcissistic and currently planning operations and hormone therapy to become female. He is also in denial about his AIDS and impending death. Stan is going to be discharged from the emergency room in two hours. The challenge the social worker faces is finding a shelter that will accept a male who looks female and has AIDS.

In addition to the immediate problem of finding a place for Stan to stay this very night, there is a broader issue here: the resistance of three different emergency shelters to accept Stan for temporary housing. This reality reflects the perceptions and attitudes of shelter staff and governing boards about the gay, lesbian, bisexual, and transgender community (GLBT) and people with AIDS.

The dilemma faced by community agencies in a major urban center in the United States is an example of the need for advocacy beyond the client level.

·  Newly proposed state regulations about a one-point access system left many staff at these community agencies confused and angry about their implementation. Staff members at these agencies are unprepared, lack knowledge about resources, and are concerned about coordination.

If you could talk with these staff members, they would tell you that no one knows better than they do about their clients’ needs and an agency’s services. Yet they had no voice in the development of these new regulations. They will be primarily responsible for implementing these regulations and resent the fact that they were not part of the development process. So there are several problems here. One is that those charged with following this new system don’t understand it. Second, this same group is integral to its success. Finally, those who know best what the issues and challenges are for themselves and their clients have no voice in this change. They want to know how they can be part of the process—or any future process where changes are planned.

Both of these examples call for advocacy at a different level than individual advocacy. The purpose of advocacy at the agency, community, state, or federal level is to promote change in any number of areas; e.g., legislation, rules and regulations, policies, statutes, budgets, attitudes, to suggest a few. Participants may be any or all of the following: other human service professionals, clients, and community representatives, and volunteers.

Why aren’t we better advocates at this level when we would probably all agree it is needed? There are many reasons for this. One, in a very practical sense, is lack of time. With large caseloads, accountability demands, and multiproblem clients, many professionals recognize that advocacy is necessary but time for this activity is a luxury. For others, it is a matter of “know how.”

How exactly does one go about advocating at this level? Many know how to speak for their clients or represent the needs of their clients in such a way that clients receive what they need. But advocacy at these more complex levels requires different skills, and helping professionals rarely have training in this area. Another problem is that many agencies and organizations discourage staff from drawing media attention, particularly that which is negative in nature, to themselves or the agency unless sanctioned by the administration. There is often a chain of command in place that must be consulted prior to any publicity. Finally, advocacy is frequently absent from any job description or job responsibilities. So there are a number of reasons for the lack of advocacy at levels greater than individual client advocacy.

One way to increase advocacy efforts is to understand the advocacy process and the skills that are required for success in this area. The process begins with the identification of a problem or a need. A temporary shelter for Stan is a problem at the client level. A broader issue is the need to increase sensitivity and services to the GLBT community. Following this initial step is the identification of targets, the entity that needs change; i.e., shelter staff, board of directors, or the community. Planning is the third step. Four strategies are identified that are named for the area in which they occur as well as the location of targets for change: agency advocacy, legislative advocacy, legal advocacy, and community advocacy (Ezell,  2001 ). The final step is implementation of the plan.

This fourth step is the one that focuses on the use of skills that are action-oriented. They include monitoring (e.g., proposals, laws, policies, practices); educating staff, clients, the community, the public, legislators, and officials; lobbying/campaigning for candidates, ideas or both by writing letters and using the media; and organizing constituents, coalitions, agencies, and networks.

If we examine each of the four strategies, then it is clear how these skills can be applied. The first is agency advocacy. This involves areas such as policies, budgets, and practices. For example, it is possible that there are some practices that are unfair or unhelpful to clients, the staff, or the community or even nonexistent, so monitoring services and programs, educating the people affected, and working with others are ways to promote any needed changes.

Legislative advocacy requires understanding the legislative process and knowing how to sell or promote your idea to a legislator, gathering support for it, and moving it through a committee or a floor vote. Lobbying skills are also often necessary. Although lobbying usually refers to persuading a local or state legislator or member of Congress to vote a certain way, staff members often lobby an administrator or board of directors to change policies and procedures. the Americans with Disabilities Act is an example of a successful effort to enact legislation that guarantees equal rights to people with disabilities and prevents discrimination against them.

Legal advocacy involves two approaches (Ezell,  2001 ). One is nonlitigious, which means that this approach is unrelated to filing lawsuits; the other involves litigation. Generally, this type of advocacy is related to the practice of law and the courts; however, it may also include both agency and legislative advocacy. Examples of successful legal advocacy that involved litigation include the right to treatment or to refuse treatment in mental health settings, the right of clients to be placed in least-restrictive environments, and the right to equal educational opportunities. An example of nonlitigious tactics is the identification of situations where clients’ rights may have been violated. In these cases, an effective advocate can assist clients in identifying when this is occurring and what resources or legal assistance is available to them.

Finally, community advocacy is a fourth strategy to change ideas and attitudes. For example, misinformation or inaccurate beliefs may be driving the adoption of a particular program or a legislative proposal. In some states, efforts are underway to prevent gays and lesbians from marrying or adopting children. In most areas there are local, state, and national organizations working for the rights of same-sex couples to marry and to adopt children. These organizations support legal defense funds, activities of lobbyists, and educational programs. These efforts support human rights and basic civil liberties. The case of Stan also illustrates the need to work with shelter staffs, governing boards, and the larger community to change attitudes and accessibility to services. There are a number of ways to educate communities with correct information; for example, interviews, letters to the editor, op-ed pieces, press conferences, presentations, and mailings. A more recent development is the use of technology to disseminate information and to educate the citizenry via the Internet and emails.

CASE STUDY: GIOAVANNI HOUSE

Giovanni House is a settlement house located in an inner city neighborhood that includes five high-rise public housing buildings. The agency works with the homeless, helps immigrants address multiple issues, and provides vocational training for clients who need work. Primary funding for the settlement house is supplied by the federal, state, and local government. The commitment of this agency has always been to advocacy, primarily for individuals in the local community. In the 1990s, Giovanni House thrived and even expanded services. With a staff of 15, the agency kept its doors open 24/7 and provided meals and temporary housing for many of its clients. Today, the settlement house maintains a staff of three professionals and four volunteers. It is open four days a week, Monday through Thursday, and recently received “stimulus” money to open on Friday.

Giovanni House staff tries to handle as much as they can in a day: they take walk-ins from the neighborhood. Volunteers staff a desk outside the main office, doing intake and identifying the needs of each person. Two staff members receive the intake forms and meet with clients who come to see them. The director provides some direct services, handles the paperwork, writes grants, and participates in coalitions all over the city that are trying to develop a new way of serving client needs. Those who need help include victims of domestic violence, elders who used to come to the settlement house for meals and programs, kids who are involved in gang activity, and immigrants who have no safe place to ask for help. Sometimes the clients wait for three or four hours to see a caseworker.

The case workers have to be “Jacks or Jills of all trades.” They have to know the city, be able to make good referrals, and provide simple solutions to complex problems. One skill that the two case workers have honed since working in this compressed environment is the ability to see the whole picture and the whole person while targeting service within the environment of limited resources. Both workers are vocal about the frustrations they feel when they have little time to meet with clients. They also have many clients who come once, receive limited services, and do not return. There are lots of open files. One policy that has emerged during the past year is matching client to staff member. The three staff decided that, if possible, clients would be seen by the same helper for each visit. Even though this is not necessarily efficient, the staff all decided it was more important to build relationships.

As a result of budget cuts, the agency may begin to shift from social services to education. This was a suggestion made by the board of directors. In their view, educational programs would reach more individuals and families in the community than one-on-one services. They suggested programs on immigration, gang awareness, and basic skills such as reading and writing. They also suggested a grief outreach program. A shift such as this asks the current staff to rethink their mission, objectives, and current service delivery. It redefines their role in the community and the type of advocacy they provide.

Exercise 5: Advocacy and Giovanni House

As you think about advocacy beyond the individual level, respond to the following questions:

1.

If you were a staff member at Giovanni House, what would you advocate for?

2.

How would you advocate for the agency?

3.

How would you address community concerns about the cutback in staff? How would you react to the board’s recent suggestion to change the mission and objectives from individual service delivery to education. How would this shift change the role of advocacy?

Exercise 6: Advocacy and Stan

Suppose you are the helping professional who works with Stan. The lack of services or the unwillingness of services to assist clients like Stan indicates a larger community problem. How might you use each of these three strategies to help with this situation?

· Community advocacy:

· Legislative advocacy:

· Legal advocacy:

Exercise 7: Advocacy and You

1.

How might you employ each of the following action-oriented skills?

· Monitoring:

· Educating:

· Lobbying/campaigning:

· Organizing:

2.

Identify a problem that you’ve encountered at your school (parking, financial aid, rules and regulations, not enough courses, and so on). Using your skills, develop an advocacy plan to address this problem. Include the four strategies introduced here and the skills you would use to implement your plan.

Exercise 8: Termination

Throughout this chapter you have read about Janis Jones, Natasha, and Stan. As you think about the termination of the helping process with each of these clients, answer the following questions.

1.

Predict how termination will occur with each one.

Janis: _______________________________________________________________

Natasha: _____________________________________________________________

Stan: ________________________________________________________________

2.

How will you prepare any client for termination?

3.

How will you prepare yourself for termination with a client?

4.

What feelings do you anticipate you will have when termination occurs

Successfully: __________________________________________________________

Unsuccessfully: ________________________________________________________

SELF-ASSESSMENT

1.

How important do you think advocacy is?

2.

How comfortable do you think you will be in the advocacy role?

3.

How will you develop your skills in this area?

REFERENCE

Ezell, M. (2001). Advocacy in the human services. Belmont, CA: Thomson/Brooks/Cole.

Back Matter

Glossary

Achievement tests

are used to evaluate an individual’s present level of functioning or what has previously been learned.

Active listening

assists the helper to hear what is said, as well as what is not said.

Applicant

is an individual who is requesting help from an individual helper or agency.

Aptitude tests

provide an indication of an individual’s potential for learning or acquiring a skill.

Assessment

is the appraisal or evaluation of a situation, the person(s) involved, or both.

Assessment interview

is an interaction that provides information for the evaluation of an individual.

Assessment phase

is the first phase of the helping process and is the diagnostic study of the client and the client’s environment.

Attending behavior

is another term for appropriate listening behaviors. Eye contact, attentive body language (such as leaning forward, facing the client, using facilitative and encouraging gestures), and vocal qualities such as tone and rate of speech are ways for the interviewer to communicate interest and attention.

Behavior changer

is the role of the helper that directs, encourages, and supports client change.

Broker

is the role assumed when the helper becomes a go-between for those who seek services and those who provide them.

Caregiver

role of helper provides support and assistance to the client based upon trust, genuineness, and unconditional positive regard.

Case history interview

is a comprehensive interview that may include a chronology of major events, the family history, work history, and medical history.

Case notes

are sometimes called staff notes and are written at the time of each visit, contact, or interaction that any helping professional has with a client. Staff notes usually appear in a client’s file in chronological order.

Case review

is the periodic examination of a client’s case.

Client empowerment

occurs when the helper encourages the client to define his or her goals, priorities, interests, strengths, and desired outcomes.

Client

is an individual who meets eligibility criteria to be accepted for services.

Client participation

means the client takes an active part in the helping process, thereby making service delivery more responsive to client needs and enhancing its effectiveness.

Closed questions

elicit facts. The answer might be yes, no, or a simple factual statement.

Codes of ethics

are written documents that articulate a profession’s guidelines for practice.

Confidentiality

is the helper’s ethical commitment to client to restrict sharing client information with informed consent unless the client indicates harm to self or others.

Coordinating services

is an action the helper engages in to link, monitor, and advocate, while building on the assessment and planning that have taken place in earlier phases of the helping process.

Crisis intervener

is a helper role that 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.

Diagnosis

involves obtaining a complete medical history and conducting a comprehensive physical exam (also called a physical, a health exam, or a medical exam).

Documentation

is the written record of the work with the client, including the initial intake, assessment of information, planning, implementation, evaluation, and termination of the case.

DSM-IV-TR

is a classification system for psychological diagnoses used in the United States and is published by the American Psychiatric Association (note it is NOT Psychological Association)

Effective communication skills

facilitate relationship building between helper and client. They include being able to listen, be empathetic, and respond in a way that encourages the development of trust and honest dialogue.

Feedback

represents questions and answers that help helpers determine if the client is on track or if some other service, action, or direction is necessary.

Feedback log

provides feedback to the helper about the nature of and the quality of service provided the client.

Goals

are statements that describe a desired state or condition or an intent.

Halo effect

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.

Implementation

is the third phase of the helping process when the service plan is carried out and evaluated.

Information and referral system

helps service providers refer clients to appropriate community agencies and organizations.

Information gathering

occurs when helper and client work together to collect relevant material such as social history and education level that help identify client problems, strengths, and support goal setting.

Initial contact

is the starting point for gathering and assessing information about the applicant to establish eligibility and evaluate the need for services.

Intake interview

occurs at the beginning of the assessment phase and provides an opportunity for the client to understand agency process and resources and for agency personnel to assess applicant eligibility for services.

Intake summary

is written at some point during the assessment phase and presents a first assessment of what was learned and observed about the applicant during the intake process.

Intelligence tests

measure verbal intelligence, nonverbal intelligence, and problem-solving ability.

Interview

is usually the first contact between a helper and an applicant for services, although some initial contacts are by telephone or letter.

Lifecycle of a disaster

represents the stages of a disaster requiring different helping responses and interventions for each stage.

Maximum performance tests

include achievement tests, aptitude tests, and intelligence tests. On these tests, examinees are asked to do their best.

Medical consultation

with a physician may provide an interpretation of medical terms and information or explain the report further and clarify possible treatments.

Medical diagnosis

appraises the general health status of the individual and establishes whether a physical or mental impairment is present.

Medical terminology

used in medical reports provides technical information and exactness.

Mental status examination

consists of questions designed to evaluate the person’s current mental status by considering factors such as appearance, behavior, and general intellectual processes.

Monitoring services

is a helper responsibility whereby 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.

Motivational interviewing

is a strategy that enhances the client’s desire to change by exploring and resolving ambivalence.

Ojective

is an intended result of service provision rather than the service itself.

Open inquiries

allow the expression of thoughts, feelings, and ideas. This type of inquiry requires a more extensive response than a simple yes or no.

Physical examination

may be part of the client’s file. It represents a physician’s taking of a medical history followed by an assessment of health or presence of disease.

Plan

is a document that describes the services to be provided, who will be responsible for their provision, and when service delivery will occur.

Plan development

is a process that includes setting goals, deciding on objectives, and determining specific interventions.

Planning

is the second phase of the helping process which includes determining future services in an organized way.

Privileged communication

is a legal concept under which clients’ “privileged” communications with professionals may not be used in court without client consent.

Process recording

is a narrative telling of an interaction with another individual.

Psychological evaluation

contributes to the understanding of the individual who is the subject.

Psychological report

is a written document that explains an individual’s personal characteristics, mental status, and social history.

Psychological test

is a device for measuring characteristics that pertain to behavior.

Questioning

with an open-ended focus helps elicit information and keep the interaction flowing.

Record

is any information relating to a client’s case, including history, observations, examinations, diagnoses, consultations, and financial and social information.

Referral

connects the client with a resource within the agency structure or at another agency.

Resource selection

involves selecting individuals, programs, or agencies that can meet the needs of the client.

SOAP

is an acronym for a case note format that supports the identification, prioritization, and tracking of client problems.

Social history

provides information about the way an individual experiences problems, past problem-solving behaviors, developmental stages, and interpersonal relationships.

Social service directory

lists the kinds of problems handled and the services delivered by other agencies.

Sources of error

in the interview represent any potential bias in a test instrument itself or in the interviewer and may result in distortions in the test scores.

Staff notes

sometimes called case notes, are written at the time of each visit, contact, or interaction that any helping professional has with a client. Staff notes usually appear in a client’s file in chronological order.

Strengths-based approach

focuses on the talents, skills, knowledge, interests, and dreams of an individual as a way to empower, motivate, and engage internal and environmental supports.

Structured clinical interview

consists of specific questions, asked in a designated order.

Structured interviews

are directive and focused; they are usually guided by a form or a set of questions that elicit specific information.

Summary recording

is a condensation of what happened, an organized presentation of facts.

Teacher

is a helper role to assist clients in developing certain skills to increase their intellectual, emotional, and behavioral options.

Termination

signifies the end of the helping process.

Test

is a measurement device.

Typical performance test

provides some idea of what the examinee is like—his or her typical behavior such as interests and personality.

Unstructured interview

consists of a sequence of questions that follow from what has been said. This type of interview can be described as broad and unrestricted.

Verbal following

is known as a minimal response; it lets the client know that the helper is listening.