A comprehensive understanding of a client’s presenting problems depends on the use of multiple types ofassessment models. Each model gathers different information based on theoretical perspective and intent. An assessment that focuses on one area alone not only misses vital information that may be helpful in planning an intervention, but may encourage a biased evaluation that could potentially lead you to an inappropriate intervention. When gathering and reviewing a client’s history, sometimes it is easier to focus on the problems and not the positive attributes of the client. In social work, the use of a strengths perspective requires that a client’s strengths, assets, and resources must be identified and utilized. Further, using an empowerment approach in conjunction with a strengths perspective guides the practitioner to work with the client to identify shared goals. You will be asked to consider these approaches and critically analyze the multidisciplinary team’s response to the program case study of Paula Cortez.
For this Assignment, review the program case study of the Cortez fami
- Utilizing two of the assessment models provided in Chapter 5 of the course text, provide a comprehensive assessment of Paula Cortez.
- Using the Cowger article, identify at least two areas of strengths in Paula’s case.
- Analyze the perspectives of two members of the multidisciplinary team, particularly relative to Paula’s pregnancy.
- Explain which model the social workers appear to be using to make their assessment.
- Describe the potential for bias when choosing an assessment model and completing an evaluation.
- Suggest strategies you, as Paula’s social worker, might try to avoid these biases.
Submit your Assignment
Paula is a 43-year-old HIV-positive Latina woman originally from Colombia. She is bilingual, fluent in both Spanish and English. Paula lives alone in an apartment in Queens, NY. She is divorced and has one son, Miguel, who is 20 years old. Paula maintains a relationship with her son and her ex-husband, David (46). Paula raised Miguel until he was 8 years old, at which time she was forced to relinquish custody due to her medical condition. Paula is severely socially isolated as she has limited contact with her family in Colombia and lacks a peer network of any kind in her neighborhood. Paula identifies as Catholic, but she does not consider religion to be a big part of her life. Paula came from a moderately well-to-do family. She reports suffering physical and emotional abuse at the hands of both her parents, who are alive and reside in Colombia with Paula’s two siblings. Paula completed high school in Colombia, but ran away when she was 17 years old because she could no longer tolerate the abuse at home. Paula became an intravenous drug user (IVDU), particularly of cocaine and heroin. David, who was originally from New York City, was one of Paula’s “drug buddies.” The two eloped, and Paula followed David to the United States. Paula continued to use drugs in the United States for several years; however, she stopped when she got pregnant with Miguel. David continued to use drugs, which led to the failure of their marriage. Once she stopped using drugs, Paula attended the Fashion Institute of Technology (FIT) in New York City. Upon completing her BA, Paula worked for a clothing designer, but realized her true passion was painting. She has a collection of more than 100 drawings and paintings, many of which track the course of her personal and emotional journey. Paula held a full-time job for a number of years before her health prevented her from working. She is now unemployed and receives Supplemental Security Insurance (SSI) and Medicaid. Paula was diagnosed with bipolar disorder. She experiences rapid cycles of mania and depression when not properly medicated, and she also has a tendency toward paranoia. Paula has a history of not complying with her psychiatric medication treatment because she does not like the way it makes her feel. She often discontinues it without telling her psychiatrist. Paula has had multiple psychiatric hospitalizations but has remained out of the hospital for at least five years. Paula accepts her bipolar diagnosis, but demonstrates limited insight into the relationship between her symptoms and her medication. Paula was diagnosed HIV positive in 1987. Paula acquired AIDS several years later when she was diagnosed with a severe brain infection and a T-cell count less than 200. Paula’s brain infection left her completely paralyzed on the right side. She lost function of her right arm and hand, as well as the ability to walk. After a long stay in an acute care hospital in New York City, Paula was transferred to a skilled nursing facility (SNF) where she thought she would die. It is at this time that Paula gave up custody of her son. However, Paula’s condition improved gradually. After being in the SNF for more than a year, Paula regained the ability to walk, although she does so with a severe limp. She also regained some function in her right arm. Her right hand (her dominant hand) remains semiparalyzed and limp. Over the course of several years, Paula taught herself to paint with her left hand and was able to return to her beloved art. In 1996, when highly active antiretroviral therapy (HAART) became available, Paula began treatment. She responded well to HAART and her HIV/AIDS was well controlled. In addition to her HIV/AIDS disease, Paula is diagnosed with hepatitis C (Hep C). While this condition was controlled, it has reached a point where Paula’s doctor is recommending she begin treatment. Paula also has significant circulatory problems, which cause her severe pain in her lower extremities. She uses prescribed narcotic pain medication to control her symptoms. Paula’s circulatory problems have also led to chronic ulcers on her feet that will not heal. Treatment for her foot ulcers demands frequent visits to a wound care clinic. Paula’s pain paired with the foot ulcers make it difficult for her to ambulate and leave her home. As with her psychiatric medication, Paula has a tendency not to comply with her medical treatment. She often disregards instructions from her doctors and resorts to holistic treatments like treating her ulcers with chamomile tea. Working with Paula can be very frustrating because she is often doing very well medically and psychiatrically. Then, out of the blue, she stops her treatment and deteriorates quickly. I met Paula as a social worker employed at an outpatient comprehensive care clinic located in an acute care hospital in New York City. The clinic functions as an interdisciplinary operation and follows a continuity of care model. As a result, clinic patients are followed by their physician and social worker on an outpatient basis and on an inpatient basis when admitted to the hospital. Thus, social workers interact not only with doctors from the clinic, but also with doctors from all services throughout the hospital. SESSIONS: CASE HISTORIES • THE CORTEZ FAMILY 24 After working with Paula for almost six months, she called to inform me that she was pregnant. Her news was shocking because she did not have a boyfriend and never spoke of dating. Paula explained that she met a man at a flower shop, they spoke several times, he visited her at her apartment, and they had sex. Paula thought he was a “stand up guy,” but recently everything had changed. Paula began to suspect that he was using drugs because he had started to become controlling and demanding. He showed up at her apartment at all times of the night demanding to be let in. He called her relentlessly, and when she did not pick up the phone, he left her mean and threatening messages. Paula was fearful for her safety. Given Paula’s complex medical profile and her psychiatric diagnosis, her doctor, psychiatrist, and I were concerned about Paula maintaining the pregnancy. We not only feared for Paula’s and the baby’s health, but also for how Paula would manage caring for a baby. Paula also struggled with what she should do about her pregnancy. She seriously considered having an abortion. However, her Catholic roots paired with seeing an ultrasound of the baby reinforced her desire to go through with the pregnancy. The primary focus of treatment quickly became dealing with Paula’s relationship with the baby’s father. During sessions with her psychiatrist and me, Paula reported feeling fearful for her safety. The father’s relentless phone calls and voicemails rattled Paula. She became scared, slept poorly, and her paranoia increased significantly. During a particular session, Paula reported that she had started smoking to cope with the stress she was feeling. She also stated that she had stopped her psychiatric medication and was not always taking her HAART. When we explored the dangers of Paula’s actions, both to herself and the baby, she indicated that she knew what she was doing was harmful but she did not care. After completing a suicide assessment, I was convinced that Paula was decompensating quickly and at risk of harming herself and/or her baby. I consulted with her psychiatrist, and Paula was involuntarily admitted to the psychiatric unit of the hospital. Paula was extremely angry at me for the admission. She blamed me for “locking her up” and not helping her. Paula remained on the unit for 2 weeks. During this stay she restarted her medications and was stabilized. I tried to visit Paula on the unit, but the first two times I showed up she refused to see me. Eventually, Paula did agree to see me. She was still angry, but she was able to see that I had acted with her best interest in mind, and we were able to repair our relationship. As Paula prepared for discharge, she spoke more about the father and the stress that had driven her to the admission in the first place. Paula agreed that despite her fears she had to do something about the situation. I helped Paula develop a safety plan, educated her about filing for a restraining order, and referred her to the AIDS Law Project, a not-for-profit organization that helps individuals with HIV handle legal issues. With my support and that of her lawyer, Paula filed a police report and successfully got the restraining order. Once the order was served, the phone calls and visits stopped, and Paula regained a sense of control over her life. From a medical perspective, Paula’s pregnancy was considered “high risk” due to her complicated medical situation. Throughout her pregnancy, Paula remained on HAART, pain, and psychiatric medication, and treatment for her Hep C was postponed. During the pregnancy the ulcers on Paula’s feet worsened and she developed a severe bone infection, ostemeylitis, in two of her toes. Without treatment the infection was extremely dangerous to both Paula and her baby. Paula was admitted to a medical unit in the hospital where she started a 2-week course of intravenous (IV) antibiotics. Unfortunately, the antibiotics did not work, and Paula had to have portions of two of her toes amputated with limited anesthesia due to the pregnancy, extending her hospital stay to nearly a month. The condition of Paula’s feet heightened my concern and the treatment team’s concerns about Paula’s ability to care for her baby. There were multiple factors to consider. In the immediate term, Paula was barely able to walk and was therefore unable to do anything to prepare for the baby’s arrival (e.g., gather supplies, take parenting class, etc.). In the medium term, we needed to address how Paula was going to care for the baby day-to-day, and we needed to think about how she would care for the baby at home given her physical limitations (i.e., limited ability to ambulate and limited use of her right hand) and her current medical status. In addition, we had to consider what she would do with the baby if she required another hospitalization. In the long term, we needed to think about permanency planning for the baby or for what would happen to the baby if Paula died. While Paula recognized the importance of all of these issues, her anxiety level was much lower than mine and that of her treatment team. Perhaps she did not see the whole picture as we did, or perhaps she was in denial. She repeatedly told me, “I know, I know. I’m just going to do it. I raised my son and I am going to take care of this baby too.” We really did not have an answer for her limited emotional response, we just needed to meet her where she was and move on. One of the things that amazed me most about Paula was that she had a great ability to rally people around her. Nurses, doctors, social workers: we all wanted to help her even when she tried to push us away. The Cortez Family David Cortez: father, 46 Paula Cortez: mother, 43 Miguel Cortez: son, 20 SESSIONS: CASE HISTORIES • THE CORTEZ FAMILY 25 While Paula was in the hospital unit, we were able to talk about the baby’s care and permanency planning. Through these discussions, Paula’s social isolation became more and more evident. Paula had not told her parents in Colombia that she was having a baby. She feared their disapproval and she stated, “I can’t stand to hear my mother’s negativity.” Miguel and David were aware of the pregnancy, but they each had their own lives. David was remarried with children, and Miguel was working and in school full-time. The idea of burdening him with her needs was something Paula would not consider. There was no one else in Paula’s life. Therefore, we were forced to look at options outside of Paula’s limited social network. After a month in the hospital, Paula went home with a surgical boot, instructions to limit bearing weight on her foot, and a list of referrals from me. Paula and I agreed to check in every other day by telephone. My intention was to monitor how she was feeling, as well as her progress with the referrals I had given her. I also wanted to provide her with support and encouragement that she was not getting from anywhere else. On many occasions, I hung up the phone frustrated with Paula because of her procrastination and lack of follow-through. But ultimately she completed what she needed to for the baby’s arrival. Paula successfully applied for WIC, the federal Supplemental Nutrition Program for Women, Infants, and Children, and was also able to secure a crib and other baby essentials. Paula delivered a healthy baby girl. The baby was born HIV negative and received the appropriate HAART treatment after birth. The baby spent a week in the neonatal intensive care unit, as she had to detox from the effects of the pain medication Paula took throughout her pregnancy. Given Paula’s low income, health, and Medicaid status, Paula was able to apply for and receive 24/7 in-home child care assistance through New York’s public assistance program. Depending on Paula’s health and her need for help, this arrangement can be modified as deemed appropriate. Miguel did take a part in caring for his half sister, but his assistance was limited. Ultimately, Paula completed the appropriate permanency planning paperwork with the assistance of the organization The Family Center. She named Miguel the baby’s guardian should something happen to her.
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Chapter 5 Assessment of Adults
Elaine Congress
Purpose: This chapter presents challenges and different evidence-informed assessments used with adult clients in a variety of practice settings. Rationale: Clients present with a range of different problems that require different assessment protocols and approaches. How evidence-informed practice is presented: A variety of assessment theories and tools used with clients who present with a variety of psychosocial problems is presented in this chapter. Overarching question: What are five essential ingredients one must consider to make an effective assessment of an adult client?
In order to provide effective evidence-based interventions with adult clients, a thorough assessment is essential. Although fundamental in planning and providing effective treatment for adult clients, assessment is a challenging endeavor. Although there are a variety of definitions of social work assessment, this chapter is based on the following definition from the Social Work Desk Reference:
Assessment is the process of systematically collecting data about a client’s func- tioning and monitoring progress in client functioning on an ongoing basis. Assessment is defined as a process of problem selection and specification that is guided in social work by a person in environment systems orientation. Assess- ment is used to identify and measure specific problem behaviors as well as protective and resilience factors, and to determine if treatment is necessary. Information is usually gathered from a variety of sources (e.g., individual, fam- ily member, case records, observation, rapid assessment tools and genograms). Types of assessment include bio-psycho-social history taking, multiple dimen- sional crisis assessment, symptom checklists, functional analysis, and mental status exams.
—(Roberts & Greene, 2002, p. 830)
Using the social work framework of person in environment, a suc- cessful assessment involves understanding the individual not only as a physical and psychological entity but also as one engaged in a relationship with both micro- and macro-environments. In looking at the intersection of this person in an environmental matrix, the social worker is in the best position to complete a comprehensive client assessment. Although many regard social work assessment as focusing on problems and diagnosis, the assessment of strengths and resilience is as important in completing a comprehensive assessment of the client. Other common features of current
125 Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and interventions. John Wiley & Sons, Incorporated. Created from waldenu on 2021-12-30 19:30:55.
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social work assessment models outlined by Jordan and Franklin (2003) include the following:
• Social work assessment models are eclectic and integrative and are not based on one underlying theory.
• Long history taking is deemphasized, and there is a focus on seeking only relevant history that is related to the function of service. For example, a social worker in a medical setting might be most interested in past and present physical health, whereas a social worker in a family-therapy agency might focus on past and present history of family relationships.
• Social work assessment involves a collaborative process between client and worker. Using an evidence-based practice (EBP) approach, the client is actively involved in sharing information with the goal of deciding on the best possible treatment. Involving the client in a short-term active participatory approach to diagnosis is the best way to ensure that the client continues to participate in treatment.
• Assessment and treatment are seen as a unified whole. There is no longer a lengthy assessment period during which clients’ needs and problems are held in abeyance. Having a short-term focused assessment enables the client to see the relevance of assessment and helps ensure that the client will remain in treatment. A corollary of this is that assessment does not end before intervention begins. Assessment continues throughout the treatment process. With an ongoing assessment process, the social worker can modify treatment based on new information that emerges from the ongoing assessment process.
A comprehensive client assessment includes many factors, both in terms of the individual (appearance, developmental history, past and current physical health, cognitive ability and style, intellectual capacity, mental status, psychiatric diagnosis, and cultural/racial identity) as well as the individual relationship to environment (role within family, family history, physical environment of home and neighborhood, and relationship to the outside community). An important part of the assessment process involves focusing not only on the deficits that a client presents but also on the client’s strengths and resilience.
There are many challenges to completing a comprehensive assess- ment of a client. First, with the current focus on short-term treatment models, a thorough assessment is often not possible. Clinicians frequently focus only on information needed to complete forms or to select an intervention. In fact, many EBP models look primarily at the client’s partic- ipation in the choice of intervention and minimize the assessment process. Yet a thorough assessment is most helpful in making the best intervention decision.
Another challenge has been that assessment is often accomplished with a singular focus. Some assessment models favor an individual
Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and interventions. John Wiley & Sons, Incorporated. Created from waldenu on 2021-12-30 19:30:55.
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psychological assessment, whereas others look more at environmental factors influencing the client. The best assessment involves an integra- tive approach that uses a broad lens for assessing clients from both bio-psychosocial and person-in-environment perspectives. Often, a rating scale, such as the one developed by Pomeroy, Holleran, and Franklin (2003), is helpful in providing a comprehensive individual assessment.
Another frequent criticism of assessment is that it often relies on a deficit model. The assessment of a client often involves diagnosis using DSM-IV. Applying only a DSM-IV diagnosis to a client focuses on a psychiatric problem and pathology and neglects strengths that should be viewed as important aspects of assessment and intervention with clients.
There is much current emphasis on accurate assessment following a traumatic event. The usual belief that having the individual relive the traumatic event has been challenged by recent evidence (Dyregrov & Regel, 2012) that suggests that rapid assessment followed by early intervention is the most effective treatment.
Historical Background
Psychosocial Diagnostic Assessment
From the birth of the social work profession, many different assessment models have been used. Perhaps the most well known is the psychoso- cial or diagnosis approach first developed by Hollis. This model relies heavily on family and developmental history to reach a psychodiagnostic assessment of the client. An ego-psychology framework (Goldstein, 2002) is fundamental to this approach. Although this approach initially focused to a large extent on a client’s developmental history, now the person/client in relationship to the current environment is stressed. According to a psychosocial-ego-psychology perspective, the assessment process has the following steps: (a) assessing the client’s interactions with his or her environment in the here and now and how successfully he or she is coping effectively with major life roles and tasks; (b) assessing the client’s adaptive, autonomous, and conflict-free areas of ego functioning as well as ego deficits and maladaptive functioning; (c) evaluating the impact of a client’s past on current functioning; and (d) examining environmental obstacles that impede a client’s functioning (Goldstein, 2002; Hollis & Wood, 1981). According to a psychosocial diagnostic approach, informa- tion for client assessment was collected in a variety of ways, including (a) psychiatric interviews to determine a diagnosis, (b) the use of standard- ized and projective testing to support diagnostic assessment, (c) current psychosocial assessment and study of prior development and adjustment to identify problem areas, (d) use of standardized interviewing to assess problem areas and current functioning, and (e) study of the client-social work relationship to ascertain client’s patterns of interactions (Jordan & Franklin, 2003).
Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and interventions. John Wiley & Sons, Incorporated. Created from waldenu on 2021-12-30 19:30:55.
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The psychosocial assessment model is well suited to today’s medi- cal model that involves the study, diagnosis, and treatment format. Many medically based behavioral-health settings use this approach. Furthermore, the focus of many behavioral-health centers on clients’ return to more adaptive functioning is also compatible with a psychosocial-diagnostic-ego- psychology model. A DSM-IV diagnosis is usually a requirement for begin- ning treatment, and thus the detailed study using a psychosocial approach is often helpful in arriving at a diagnosis. Structured assessment tools, such as the eco-map (Hartman & Laird, 1983) and the genogram (McGoldrick, Gerson, & Schallenberg, 1999), are also helpful for practitioners in com- pleting assessments. There is a need for more outcome-focused research, however, on the effectiveness of using these instruments. Finally, the devel- opment of standardized semistructured interviews using a psychosocial approach is most helpful in promoting current evidence-based assessment.
Problem-Solving Assessment
Another major assessment model was the problem-solving assessment originally developed by Helen Harris Perlman in 1957. This model is based on the psychosocial diagnosis model described earlier and the functional model that focuses on growth and potential as well as agency function. Perlman saw assessment as an eclectic model with four Ps—person, problem, place, and process—as a way to organize information about the client. In terms of person, the social worker should think of the client’s personality characteristics and which interactions with the environment are significant. A second area involves a focus on problem: How can the problem be defined? Is it a crisis, a repetitive issue? What other ways has the client sought to resolve the problem? The third category is place or agency. What concerns does the client have about contact within the agency? What is most helpful and what is most harmful about the agency in the process of client assessment? The fourth relates to process. Which intervention will be most successful? What will be the consequences of a particular choice of treatment?
Current assessment still relies a great deal on the problem-solving approach to assessment. First, a very quick assessment tool, such as that outlined by Perlman, is most helpful in the current social-service environment, with its focus on short-term assessment and intervention. Another advantage, especially for culturally diverse clients who may be fearful of interaction with the agency, is the inclusion of Perlman’s third P—place—in the assessment process. This approach encourages the social worker to look at how the fears and feelings that clients may have about the agency affect the assessment process. This may be especially true for undocumented clients who are apprehensive that social workers will use their power and authority to report their immigration status.
There are two major concerns about the problem-solving approach as used in current assessment practice. First, there is limited attention to the person’s strengths and resilience in resolving the problem. Modern
Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and interventions. John Wiley & Sons, Incorporated. Created from waldenu on 2021-12-30 19:30:55.
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assessment models seek to focus specifically on the strengths a client brings to the situation. The client’s definition of the ‘‘problem’’ and what strengths he or she can use and has used in the past to address the problem are considered key. Another major concern about the problem- solving approach is that it is based primarily on practice wisdom, with limited empirical research to support its use. With the emphasis on EBP, research is needed to ascertain the effectiveness of this assessment model as a foundation for treatment interventions with diverse clients.
Cognitive-Behavior Assessment
Cognitive-behavior assessment models have made a major contribution to current practice and research about assessment. Meichenbaum (1993) out- lines three metaphors that have guided this complex model—conditioning, information processing, and constructive narrative. Early cognitive behav- iorists focused primarily on conditioning as the way certain behaviors were learned. Then the focus shifted to a greater emphasis on cognitions, social learning, and the development of belief systems. Most recently, the focus has been on the use of client narratives and life stories as part of the assessment process.
Jordan and Franklin (2003) identify four attributes of cognitive behav- ior assessment that are particularly useful in today’s practice:
1. Because much of today’s practice focuses on short-term intervention, the focus on rapid assessment and treatment is particularly useful. Assessment includes history only as it is related to the client’s current functioning, but the main focus is on identifying the faulty learning and cognitive patterns that have contributed to current maladaptive behavior.
2. Much research has been conducted on outcomes of cognitive behavior approaches. This is particularly useful with today’s emphasis on evidence-based assessment and treatment.
3. Many assessment and treatment manuals for use with assessing a number of identified client problems, such as depression, substance abuse, personality disorders, and posttraumatic stress disorder, have been developed using the cognitive-behavioral approach.
4. Ongoing assessment has been stressed as essential in evaluating the effectiveness of treatment. The integration of assessment with treatment is very much part of current beliefs about assessment.
Life-Model Assessment
The life-model assessment (Germain & Gitterman, 1996) uses an ecological framework that focuses on the client’s interactions with the environment in three main areas—life transitions, environmental pressures, and mal- adaptive interpersonal processes. Major aims of this theory are to closely link person and environment, stress the client’s perspective, and provide linkages among direct service, administration, and policy planning.
Holosko, M. J., Dulmus, C. N., Sowers, K. M., & Sowers, K. M. (2013). Social work practice with individuals and families : Evidence-informed assessments and interventions. John Wiley & Sons, Incorporated. Created from waldenu on 2021-12-30 19:30:55.
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130 Social Work Practice With Individuals and Families
There has been some concern that the life-model assessment does not guide current practice interventions very well (Wakefield, 1996). With the need for short-term evidence-based assessment and intervention, the weakness of this link is problematic. The ecological model, however, has served as a foundation for developing multisystematic therapy, an evidence-based therapy that has proven to be useful with youth and fam- ilies (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998). An assessment tool, such as the eco-map (Hartman & Laird, 1983) that is based on the life-model ecological approach, has been useful, although research on this has been limited. Computer software programs may help practitioners use this assessment tool more effectively, standardize its use, and provide more opportunities for research about its effectiveness.
Task-Centered Assessment
The task-centered assessment model developed by Reid (1988) focuses on specific target problems and their desired outcomes. Major steps in this model include task planning, implementation, and review. Task plan- ning builds on initial problem formulation. The client’s perception of the prob