Week 08 - Assessments - Gathering Information and Formulating Understanding of Clients
A presentation at Heritage University at CBC Week 08 in in Pasco, WA 99301, USA by Jacob Campbell
SOWK 486 Fall 2019 Planning: Class 08
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
Agenda
- Diagnostic Assessments
- DSM-5
- Mini Mental Status Exams
The Multidimensionality of Assessment
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.
Priorities in Assessment
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?
Ethical Considerations Regarding Clinical Work
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
Using the DSM
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
Problems Related to the DSM
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
DSM Sections
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
Emphasizing Strengths in Assessments
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
Emphasizing Strengths in Assessments
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
How Observant Are You?
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.
Conditions Surrounding Troubling Behaviors
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?
Sources of Information for Assessments
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.
Problem Assessment
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.
Systems of Interaction
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 Needs
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.
How I Write My Notes
I wanted to show how I write my notes.
- Plain text
- Giving basic information
- TextExpander
General Components of a MSE
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 (1 of 4)
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
General Appearance (2 of 4)
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
General Appearance (3 of 4)
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
General Appearance (4 of 4)
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)
Emotions
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)
Cognitive Functioning (1 or 2)
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)
Cognitive Functioning (2 or 2)
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 Perception (1 of 3)
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
Thoughts and Perception (2 of 3)
- 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
Thoughts and Perception (3 of 3)
- Preoccupations
- Somatic preoccupations
- Obsessions
- Compulsions
- Phobias
- Suicidality, Homicidality, Impulse control
- Insight and Judgment
Suicide Risk Assessment (1 of 5) - Adults
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
Suicide Risk Assessment (2 of 5) - Youth
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)
Suicide Risk Assessment (3 of 5) - Ask Directly
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.
Suicide Risk Assessment (4 of 5) - Assess in Detail
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
Suicide Risk Assessment (5 of 5) - Other Risk Factors
Then finally we have to assess other risk factors
- Hopelessness
- Impulsivity
- Protective factors (deterrents)
- Warning signs (imminent risk)
The Checklist Manifesto: How to Get Things Done Right
- Great book
- Concept of having checklists for things that you need to asses.
Adequacy of Client’s Environments.
- 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
Intrapersonal Functioning
- 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
Assessing Aggression
(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
Assessing Person-In-Environment Fit
- 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
Biopsychosocial Assessments
(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.
Common Role and Developmental Transitions for Older Age Group
- 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
Common Role and Developmental Transitions for Younger Age Group
- 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
Typical Wants Involved in Presenting Problems
- 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
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
