Week 08: Assessment in Social Work
A presentation at Heritage University at CBC Week 08 in in Pasco, WA 99301, USA by Jacob Campbell
SOWK 486 Fall 2020 Planning: Class 08
Location: Online - Zoom
Time: Monday’s from 5:30-8:15
Week 08: 10/12/20
Topic and Content Area: Assessments
Reading Assignment: Hepworth et al. (2017) chapters eight and nine
Assignments Due:
- A–02: Asynchronous Class Engagement No assignment, time to prepare for synchronous class presentation week 9 about what to assess for within a group.
- A–03: Reading Quiz for chapters eight and nine is due at 5:30 PM before class via My Heritage
Other Important Information: N/A
Agenda
- Diagnostic Assessments
- Screening Tools
- DSM-5
- Documentation
- 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
Framework for Strengths in Assessment
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
Numerous sources of information can be used individually or in combination. The following are the most common:
- Background sheets or other intake forms that clients complete
- Interview with clients (e.g., accounts of problems, history, views, thoughts, events, and the like)
- Direct observation of nonverbal behavior
- Direct observation of interaction between partners, family members, and group members
- Collateral information from relatives, friends, physicians, teachers, employers, and other professionals
- Tests or assessment instruments
- Personal experiences of the practitioner based on direct interactions with clients
Introduction - Managing Stress - BBC
College and life is stressful. The following is a short video clip about managing stress by the BBC.
[Whole Class Activity] Watch video clip
Perceived Stress Screener (1 of 2)
We are going to talk some about screening tools. The Global Measure of Perceived Stress, original published by Cohen et al. in 1983, is a tool. I didn’t want to choose a tool that would be too intrusive and that might still be useful. In class, I’ve generally printed and had students complete about five different screeners to see how each of them work. Today we will just do this one.
[Whole Class Activity] Write on a sheet of paper your rating for each of the numbers (make sure to number your answer)
- In the last month, how often have you been upset because of something that happened unexpectedly?
- In the last month, how often have you felt that you were unable to control the important things in your life?
- In the last month, how often have you felt nervous and stressed?
- In the last month, how often have you felt confident about your ability to handle your personal problems?
- In the last month, how often have you felt that things were going your way?
- In the last month, how often have you found that you could not cope with all the things that you had to do?
- In the last month, how often have you been able to control irritations in your life?
- In the last month, how often have you felt that you were on top of things?
- In the last month, how often have you been angered because of things that happened that were outside of your control?
- In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
For each question choose from the following alternatives: 0 - never 1 - almost never 2 - sometimes 3 - fairly often 4 - very often
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A Global Measure of Perceived Stress. Journal of Health and Social Behavior, 24(4), 385. https://doi.org/10.2307/2136404
Example taken from the New Hampshire Department of Employee Assistance Programs: https://das.nh.gov/wellness/Docs/Percieved%20Stress%20Scale.pdf
Perceived Stress Screener (2 of 2)
Score yourself
- Reverse your scores for questions 4, 5, 7, and 8. On these 4 questions, change the scores like this: 0 = 4, 1 = 3, 2 = 2, 3 = 1, 4 = 0.
- Add up your scores for each item to get a total.
Individual scores on the PSS can range from 0 to 40 with higher scores indicating higher perceived stress.
- Scores ranging from 0-13 would be considered low stress.
- Scores ranging from 14-26 would be considered moderate stress.
- Scores ranging from 27-40 would be considered high perceived stress.
The Perceived Stress Scale is interesting and important because your perception of what is happening in your life is most important. Consider the idea that two individuals could have the exact same events and experiences in their lives for the past month. Depending on their perception, total score could put one of those individuals in the low stress category and the total score could put the second person in the high stress category
[Small Group Activity] Students will be broken up into small groups to consider their scores for the Perceived Stress Screener
- How accurate was your do you feel this was
- How is completing a screener useful for the worker
- How is completing a screener useful for the client
[Whole Class Activity] Have discussion about how we can use screeners and why we might use them.
Examples of the Screeners - PHQ-9 - Depression Screener
PHQ-9 - Depression Screener
Examples of the Screeners - GAD-7 - Generalized Anxiety
GAD-7 - Generalized Anxiety
Examples of the Screeners - GAIN-SS
GAIN-SS - Internalizing, externalizing, and substance abuse.
Examples of Screener Forms Psychiatric Mental Health Nurse Practitioner
Show the various tools at PMH-NP
A-02 Asynchronous Participation - Preparation for In-Class Teach Back
This assignment is going to be a part of participation in class for week 09. There is no other assignments either this week or next to have time to prepare for it.
Purpose: For students to be able to both increase knowledge around assessment and to facilitate learning for peers about what to examine in various assessments.
Task: Students will work in small groups to plan a presentation to take place during class on 10/19/20. Students will prepare a short five to 10 minute presentation to talk about what social workers should be looking for in various aspects of assessments. During class 10/12/20 students will be divided up into four groups. Each group will be assigned one of the following out of the textbook:
- Suicide Risk Assessment (pp. 230-234)
- Assessing Aggression (pp. 236-237)
- Assessing Environmental Systems (pp. 237-241)
- Assessing Biophysical Functioning (pp. 218 - 224)
Students are to prepare to share information and have a discussion with classmates about their selected area. Students may choose to create a presentation that can be completed during class. The goal is to help classmates know how to assess for the given topic and have a group discussion about the topic.
Criterion for Success: Students will show they are prepared in class on week nine to facilitate both information about their topic and have discussion with their fellow students.
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
Week’s eight and nine are both about how social workers conduct assessments. After we have started building relationship with our clients, and before we can really find ways to support them we have understand what the real problem is. We will be looking at how we do assessments. We will review examples of screening tools, the DSM-5, and mini mental status exams. As well we are going to spend time discussing documentation.
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