SOWK 486 Week 08 - Assessments - Gathering Information and Formulating Understanding of Clients

A presentation at Heritage University in October 2019 by Jacob Campbell and is tagged with BASW Program, Heritage University, SOWK 486w

Location: CBC Campus - SWL 206 Time: Wednesday from 5:30-8:15 Week 08: 10/07/19 — 10/13/19 Reading Assignment: Hepworth et al. (2016) Chapters 8 & 9 Topic and Content Area: Assessment Assignments Due: Reading Quiz Other Important Information: N/A

Diagnostic Assessments DSM-5 Mini Mental Status Exams

Assessments give a social worker the ability to “gathering information and formulating it into a coherent picture of the client and his or her circumstances” (p. 187) When we are thinking about assessments, we generally think about them as being multidimensional. Complex Interplay: Human problems even those that appear to be simple at first glance—often involve a complex interplay of many factors. Rarely do sources of problems reside solely within an individual or within that individual’s environment. Complex Social Institutions: The multidimensionality of human problems is a consequence of the fact that human beings are social creatures who depend both on other human beings and on complex social institutions to meet their needs. Person’s functioning: Assessing the functioning of an individual entails evaluating various aspects of that person’s functioning.

Although a social worker’s assessment will be guided by the setting in which the assessment is conducted, certain priorities in assessment influence all social work settings. Initially, three questions should be assessed in all situations: What does the client see as his or her primary concerns or goals? What (if any) current or impending legal mandates must the client and social worker consider? What (if any) potentially serious health or safety concerns might require the social worker’s and client’s attention?

As students, and especially BA social work students, we want to discuss a little bit of the limitations of this. It should be self evident, but… Who gives diagnoses? [Whole Class Activity: Discussion] Who general gives diagnoses? (think about autism and who general ascribe those diagnoses) Students role in understanding clinical practice It’s about have a common language In reading reports Introduction to clinical terminology

The Diagnostic and Statistical Manual of Mental Disorders is a collection of diagnoses of mental disordered accompanied by the typical behaviors and symptoms you might see in a particular diagnosis. [Discussion] How much do you know about the DSM? [Discussion] What is the purpose of the DSM —> Click Common language Billing Research

While the DSM is prolific and used everywhere, there are some problems that are related to the DSM? [Discussion] What are some of the problems people have with use of a medical model for diagnoses Not strengths based (other citation…) Possible loss of personal freedom (recommendations of specific treatments) Lifelong labeling Variance of diagnoses among professionals (other citation) Shackle, E. M. (1985). Psychiatric diagnosis as an ethical problem. Journal of Medical Ethics, 11(9), 132–134. doi:10.1136/jme.11.3.132

The Diagnostic and Statistical Manual, Fifth Edition (DSM-5) is an important tool for understanding and formulating mental and emotional disorders (American Psychiatric Association, 2013b). For each disorder, the manual uses a standardized format to present relevant information. The sections contain: Diagnostic criteria Subtypes/specifiers Recording procedures Diagnostic features Associated features supporting diagnosis Prevalence Development and course Risk and prognostic factors Specific culture, gender, and age features Functional consequences of the specific diagnosis Differential diagnosis Comorbidity

To emphasize strengths and empowerment in the assessment process, Cowger (1994) as cited in the text book made three suggestions to social workers: Give pre-eminence to the client’s understanding of the facts Discover what the client wants Assess personal and environmental strengths on multiple levels

from saleebey, D. (2009) The strengths perspective in social work practice (2nd ed.) Pearson Education inc: Upper Saddle River New Jersey 4 quadrants Strengths or Resources Vs. Deficit, Obstacle, or Challenges And Environmental factors (family, community) Vs. Individual or personal factors

The following is a short video. So, you all have at least gotten your AA. I want to do a short little test to see how well you can count. We are going to watch a short movie clip of two teams (a black one and a white one) passing the ball. Make sure that you keep an accurate count! [Activity] Watch the video clip [Discussion] How many did you count? How many of you noticed the gorilla moon walking through the background? Context is important when we think about our clients situations.

Assessment focuses on the conditions surrounding troubling behaviors, the conditions that reinforce the behavior, and the consequences and secondary gains that might result. Questions to address this sequence include: When: When do you experience the behavior? Where: Where do you experience the behavior? Duration: How long does the behavior usually last? Consequences: What happens immediately after the behavior occurs? Physiological: What bodily reactions do you experience with the behavior? Social: What do the people around you usually do when the behavior is happening? Reinforcement: What happened after the behavior that was pleasant?

Good practice requires social workers to use a variety of communication methods to encourage the client to tell his or her story. Social workers’ initial contacts with clients will concentrate on… Identifying the presenting problem Uncovering the sources of this problem Engaging the client in planning appropriate remedial measures.

Good practice requires social workers to use a variety of communication methods to encourage the client to tell his or her story. Social workers’ initial contacts with clients will concentrate on… Identifying the presenting problem Uncovering the sources of this problem Engaging the client in planning appropriate remedial measures.

A portion of the assessment should include information regarding the the various systems they interact with People commonly interact with the following systems: The family and extended family or kinship network The social network (friends, neighbors, etc.) Public institutions (educational, recreational,etc.) Personal service providers (doctor, dentist,etc.) The faith community (religious leaders, lay ministers, etc.)

Determining unmet needs, then, is the first step in identifying which resources must be tapped or developed. In determining clients’ unmet needs and wants,it is essential to consider the developmental stage of the individual, couple, or family. [Whole Class Activity] Discuss how we asses needs along with the difference between needs and wants.

I wanted to show how I write my notes. Plain text Giving basic information TextExpander

The following are the general parts of a MSE General appearance Behavior Thought process and content Affect Impulse control Insight Cognitive functioning Intelligence Reality testing Suicidal or homicidal ideation Judgment [Discussion] Do we use formalized words in our documentation? [Discussion] Mental Status Examination vs Mini Mental Status Examination

General appearance is one aspect that is evaluated by workers as a part of a diagnostic process. —> Appearance Grooming Meticulous (too perfect) Skillfully applied Garish (outlandish) Self-neglect Dress Immaculate (too neat) Unconventional (odd) Fashionable (think small town) Physical characteristics Outstanding features (tattoos, missing part of hand… etc) Build (emaciated, thin, average, stocky, obese) Important physical features Disabilities Posture and gait Use of mobility device Slumped

Along with the appearance is… Attitude and Interpersonal Style Hostility Uncooperative Inappropriate boundaries Seductive Playful Ingratiating (what ever you say goes) Guarded Sullen Passive Manipulative Contemptuous (superior, sneering cynical) Demanding Withdrawn

Facial expressions and psychomotor activity are both included in the general appearance of the client. Facial expression Bland (intense material, but looks casual) Flat (no facial expression) Liable (rapid changes) Behavior and Psychomotor activity Seated quietly (limited movement) Hyperactive (Busy with hands and or feet) Agitated (unable to sit still) Combative Awkward (Unable to manage activity) Rigid Mannerism (unconscious repetitive motions) Posturing (certain postures and holds inappropriately) (think duel meaning) Tics and twitches (involuntary movements) Motor hyperactivity Motor retardations (slowly) Tension Severe akathisia (severe restlessness) Tardive dyskinesia (Late appearing abnormal movements) (Anti-psychotic medications) Catatonic behavior

Speech and language is also a part of the general appearance. Speech and Language Pressured Monotonous Emotional Accented (slp stuff) Impoverished Neologisms (New words) Aphasia (Inability to understand / produce language) Global aphasia (Not speak, understand, write, repeat, name objects) Broca’s aphasia (understand, but trouble expressing own thoughts) Wernike’s aphasia: (Inability to express words - Word salad - uses bizarre / non nonsensical speech) Dysarthria (difficulty articulating due to problems with the mechanisms that produce speech) Perseveration (repeating verbal or motor response) Stereotypy (constant repetition of speech or actions)

Reporting on emotions is an important aspect of client assessment as well. Neurovegetative (autonomic - acting or occurring involuntarily) can be signs of depression. Neurovegetative symptoms are symptoms leading to dissociation from society as a whole. Symptoms include physical, emotional and cognitive changes. When the symptoms combine as in depression, they work in unison to cause a further decline in the mental state of the patient. This downward spiral can be overlooked until the depression is in an extreme state.) Mood Euthymic (normal mood) Expansive (improvement) Euphoric Anxious Clients description Affect (the external expression of emotion attached to ideas or mental representations of objects) Broad (Normal range of mood) Appropriate Constricted (reduction in the intensity of affect, to a somewhat lesser degree than is characteristic of blunted affect) Blunted (severe reduction in the intensity of affect; a common symptom of schizophrenic disorders) Flat (lack of emotional expression.) Labile (rapid changes) Anhedonic (incapable of pleasure) Emotional withdrawal Full range of affect Congruent with mood Sleep Initial insomnia (trouble falling asleep) Middle insomnia (waking in the night) Terminal insomnia (Early morning waking) Hypersomnia (over sleeping)

Another area that is that of a clients cognitive functioning. Orientation and level of consciousness Lethargy (trouble remaining alert) Obtundation (Difficult to arouse) Stupor (semi-comatose) Coma (unable to arouse) Oriented Times Four (person, time, place, Context) Attention and concentration Serial 7’s (3’s, spelling word world backwards) Memory Registration (gaining memories) Retention (keeping it) Retrieval (calling it back) Short term memory Long term memory Amnesia (inability to remember) Anterograde amnesia (cannot learn new material) Retrograde amnesia (inability recall past events) Head Injuries (TBI) Transient global amnesia (sudden confusion, loss of memory, disorientation… etc)

As well there can be… Memory Testing Immediate recall (digits adding one digit a time, significant if fails 5 or less digits) (think anxiety depression) Recent memory (apple penny table) Remote memories (information about life, major events… etc) Ability to Abstract and Generalize Proverbs (psychosis) Similarities and differences (apples and oranges) Information Intelligence Basic facts about figures… etc Fund of knowledge

Thoughts and perceptions are another area that we evaluate. Disordered Perceptions Illusions Hallucinations Depersonalization (feeling detached from self) Dearealization (Feeling detached from what is real and not real) Thought Content Distortions (part of reality) (think anaxeia) Delusions (Inappropriate idea of reality) Paranoid delusions Thought withdrawal (thoughts taken from one’s mind) Thought insertion Though broadcasting (others can hear) Suspiciousness Grandiose delusions Somatic delusions (false beliefs about ones health) Delusional guilt (falsely believing guilty) Nihilistic delusions (meaninglessness of life) Ideas of inference (false beliefs of what others do to him) (shooting apartment) Ideas of reference (people are thinking about person) Magical thinking (think about religious beliefs, cognitive level… etc) Thought content (specify what is in the thoughts) Bizarre behavior

Thought Process - Flow of Ideas (quality of associations) Spontaneous (without asking questions) Goal directed Impoverished Racing thoughts blocking (pausing) Circumstantial (too many irrelevant ideas) Persevrative Loose association (not logical) Flight of ideas (jumping from idea to another in logical sequence) Illogical Incoherent Neologism (new words) Distractable Clang association (Sound of word rather than idea) Tangentiality Overvalued (ideas might be possible, but used incorrectly) Conceptual disorganization

Preoccupations Somatic preoccupations Obsessions Compulsions Phobias Suicidality, Homicidality, Impulse control Insight and Judgment

I wanted to spend some special time just looking at suicide risk assessment. The first step is to listen to risk factors. For adults they can be: Feelings of despair and hopelessness Previous suicide attempts Concrete, available, and lethal plans to commit suicide (when, where, and how) Family history of suicide Perseveration about suicide Lack of support systems and other forms of isolation Feelings of worthlessness Belief that others would be better off if the client were dead Advanced age (especially for white males) Substance abuse

for youth, the following are some areas that we might want to consider. Deterioration in personal habits Decline in school achievement Marked increase in sadness, moodiness, and sudden tearful reactions Loss of appetite Use of drugs or alcohol Talk of death or dying (even in a joking manner) Withdrawal from friends and family Making final arrangements, such as giving away valued possessions Sudden or unexplained departure from past behaviors (from shy to thrill-seeking or from outgoing to sullen and withdrawn)

Have you have thoughts about death or suicide? Written about in all of the literature and the best practice. Focus on being non-judgmental Gets easier as you go through.

I’d like to ask you more about that. We need to ask more about risk factors, plan, intent, history… etc. The biggest things to get more details about: History Thoughts Plan Intent Means

Then finally we have to assess other risk factors Hopelessness Impulsivity Protective factors (deterrents) Warning signs (imminent risk)

Great book Concept of having checklists for things that you need to asses.

A physical environment that is adequate, is stable, and fosters health and safety (this includes housing as well as surroundings that are free of toxins and other health risks) Adequate social support systems (e.g., family, relatives, friends, neighbors, organized groups) Affiliation with a meaningful and responsive faith community Access to timely, appropriate, affordable health care (including vaccinations, physicians, dentists, medications, and nursing homes) Access to safe, reliable, affordable child and elder care services Access to recreational facilities Transportation—to work, socialize, utilize resources, and exercise rights as a citizen Adequate housing that provides ample space, sanitation, privacy, and safety from hazards and pollution (both air and noise) Responsive police and fire protection and a reasonable degree of security Safe and healthful work conditions Sufficient financial resources to purchase essential resources (e.g., food, clothing, housing) Adequate nutritional intake Predictable living arrangements with caring others (especially for children) Opportunities for education and self-fulfillment Access to legal assistance Employment opportunities

Biophysical Functioning Physical characteristics and presentation Physical health Use and abuse of medications, alcohol, and drugs Alcohol use and abuse Use and abuse of other substances Dual diagnosis: comorbid addictive and mental disorders Cognitive/Perceptual Functioning Intellectual functioning Judgment Reality testing Coherence Cognitive flexibility Values Misconceptions Self-concept Assessing thought disorders Affective Functioning Emotional control Range of emotions Appropriateness of affect Assessing affective disorders Bipolar disorder Major depressive disorder Suicidal risk Depression and suicidal risk with children, adolescents, and older adults Behavioral Functioning Excesses Risk of violence Deficiencies Motivation

(Hepworth, et al., 2017) (Adapted from Houston-Vega, Nuehring, & Daguio, 1997, pp. 97–101) Personal history: Child abuse or neglect; early exposure to violence in the family; problems at school, including threats, fights, or assaults on teachers; antisocial behavior; learning disabilities, ADHD, low IQ, head injury, or other physical problems Interpersonal relationships and social supports: Client’s attitude toward people in general; how the client interacts with the practitioner; if the client has close friendships; how the client relates to members of the opposite sex; recent changes in relationships; difficulties with social interaction Psychological factors: Active substance use or abuse; manic phase of bipolar disorder; acute psychosis in paranoid schizophrenia; antisocial, borderline, or paranoid personality disorder; low empathy, impulsivity, intermittent explosive disorder, and inability to delay gratification Physical conditions: Intoxication; temporal lobe epilepsy; dementia, delirium; history of head trauma History of violence: How long has the client been getting into fights? How often? How badly has the client ever hurt someone? Does the client have a criminal record? Past hospitalization because of violent behavior? Current threats and plans of violence: Is the client currently angry at anyone? Is there anyone the client would like to hurt or kill? Where is this person now? Does the client have access to a weapon? How would the client carry out the threat? Where? Current crisis and situation: Current mood and behavior of the client; memory difficulty; poor concentration; poor coordination; exaggerated preoccupation with sexual thoughts and fantasies; nonadherence to medication; recent release from incarceration

Environmental Systems Physical environment Adequacy Health Safety Social support systems Missing Affirming Harmful Spirituality and affiliation with a faith community Spirituality Religion Cognitive, affective, and behavioral dimensions of faith

(Ross, 2000) Identifying information (e.g., name, age, referral source, brief overview of the presenting problem) A history of the present circumstances (i.e., the presenting problem, symptoms) The past psychiatric and medical history of the client and the client’s family (e.g., injuries, operations, medical conditions, medication, ongoing medical treatment) The client’s social history (e.g., overview of client’s childhood, family structure, living situation, employment and employment history, educational history, hobbies, daily routine, religious or spiritual preferences, friends, past trauma, substance use) A mental status exam (see Figure 9-2, p. 235) and DSM-5 diagnosis A formulation (e.g., a statement that summarizes and synthesizes the most important aspects of the case to create a story of the client and his or her past and presenting problems) For children and adolescents, a brief overview of developmental milestones may be included, addressing the age at which he/she began crawling, walking, talking, toilet training, and so on.

Work, career choices Health impairment Parenthood Post-parenthood years Geographic moves and migrations Marriage or partnership commitment Retirement Separation or divorce Institutionalization Single parenthood Death of a spouse or partner Military deployments

Changing grades, especially transitioning to middle school or high school The birth of a sibling Illness of a parent or caregiver Loss of social status at school through bullying or peer victimization Breaking up with a dating partner The loss of a friendship either through death or argument Death of a parent or caregiver Personal illness Questions surrounding sexual identity Addition of a new stepparent to a divorced family

To have less family conflict To feel valued by one’s spouse or partner To be self-supporting To achieve greater companionship in marriage or relationship To gain more self-confidence To have more freedom To control one’s temper To overcome depression To have more friends To be included in decision making To get discharged from an institution To make a difficult decision To master fear or anxiety To cope with children more effectively

Portrait style photo of Jacob Campbell

Dr. Jacob Campbell

42 slides

Description

Assessments is all about gathering information and formulating it into a coherent picture of the client and his or her circumstances. The agenda for this week is as follows:

Diagnostic Assessments
DSM-5
Mini Mental Status Exams