Building your social work practice toolbox: theories & techniques for working with individuals, groups & families
Monday, October 19, 2015
Assessment
Please review the following brief video clip of an initial interview. Offer some comments about the assessment techniques that you observe. What additional questions would you ask during this interview?
Hi all, The interaction was very, very brief and did not collect a lot of information. There was no Bio-Psycho-Social Assessment or safety assessment. There also seemed to be several missed opportunities to console the client and to ask additional questions. If a client presented to my office talking about the inability to get out of bed and crying I would complete a safety assessment before allowing her to leave. This seemed to be many missed opportunity to also build a relationship with the client, but Susie stuck to simple questions almost dismissing her reports of physical symptoms. I would have let the client take the lead and let her discuss the information she felt was important to why she was now seeking help. If I was Susie the SW these are the additional questions I would ask. Can identify times in your life when you didn't feel this way?
Can you identify what triggers your anxiety?
What things have worked for you in the past to manage those feelings?
Have you ever worker with a therapist or psychiatrist to address your anxiety or depression? If so, what coping skills did you learn that worked for you?
Why now, what’s different about your anxiety or depressions that has led you to seek help?
When was the last time you saw your doctor and had a medical screening? Are you taking any medications for depression or anxiety?
When was the last time you drank or used recreational drugs? Do you feel there is a connection with when you feel anxiety or depressed and when you are likely to use again?
Do you ever have thoughts of harming yourself? If so, what other ways have you thought of?
Do you feel safe returning home today?
Do you have a history of suicide attempts?
What motivated you to get out of bed on those really hard days? What else has worked for you in the past?
Absolutely, Jennifer! All great ideas. Sue social worker is a fun way to get you rolling. I expected you all might have some additional ideas. And a five minute role play will never offer as much as a real hour long assessment. Thanks so much for starting us off with all your great suggestions.
Great ideas. I agree with all of your questions. Since the client reports feeling anxiety since childhood, I think it is important to ask the client if anything has been helpful in managing these feelings. Even if coping skills have been negative such as substance abuse and/or self harm, it can be a great starting point and provide greater insight.
I believe Sue social worker did a great job of attempting to understand the client’s presenting problem and what brought her into treatment. She asked good follow up questions regarding how long she has been experiencing anxiety as well as how she can tell she is anxious (sometimes this can get confused with other symptoms so it is important to verify). I also found it appropriate that she reinforced to the client that her anxiety is treatable and provided insight that they could work on the problem together. In order to get a better understanding of the client’s situation I would conduct a mental status (client’s appearance, facial expressions, movements, quality of speech, mood, feelings, risk assessment, orientation, etc). I might also begin a bio-psycho-social assessment with the client to get a better understanding of perhaps her history and other needs (ie: family structure, employment, housing, medical history, psychiatric history). This may lend some clues as to why she is experiencing this anxiety and help determine if she has received treatment for this sort of anxiety in the past. I always think it is important to ask clients in every session about suicidal or homicidal risk (which would fit into mental status), but I also like to ensure that their basic needs are being met (ie: food, clothing, etc). If a client is struggling with their most basic needs it may be appropriate to focus on those essentials which very well may be adding to some of their symptoms (ie: anxiety or depression).
More great ideas! Thank you, Rebecca! Assessment is a critical social work skill and many of you have had experience with this last year and in your employment situations. You are great resources for us. Keep the ideas coming!
Mental status exams are usually not my first go-to assessments (this could be because at my placement the doctors in admissions completes this before I meet patients). However, I do see where they can be valuable in assessing how symptoms and disorders are impacting a person's life. I believe we can get a lot of information in regards to a person's functioning and care of themselves by their appearance, mood, speech etc. Thanks for brining this us.
It's a good idea you brought up to do a little sleuthing about her living and/or social situation to figure out what could be the cause of her anxiety. Although she does say that she's had anxious episodes ever since childhood, that doesn't mean they're not being exacerbated acutely by an immediate problem in her life. And, if that's the case, then it's important for her counselor to know about it.
Beyond confirmation that the prospective client has, one, come to the right place for services and, two, was comforted by Susie by the facts that anxiety and depression are very treatable, the assessment has hardly begun. It has only been established, in other words, that the prospective client is symptomatic of disorders that Susie's agency treats.
In terms of assessment technique, which we've seen little of, Susie's demeanor/behavior strikes me as a harbinger of a medical model technique rather than a social worker's technique grounded in "person-in-environment."
To begin, I'd want to know how the client identifies herself and how she characterizes the contexts (i. e. home, work) that further define her being.
I thought that the therapist spoke with the client in a very calm tone. I found this to be a very brief assessment and the only information that I was able to gather from it was that she had anxiety.
I would ask if she has been in treatment in the past and if so was it beneficial for her and what things were beneficial?
I would ask her what motivated her to come in today to see me?
I would ask her who are her supports?
I would ask if she has ever harmed herself or others and if she currently felt safe.
Christine Mc.
The client described the anxiety almost as if she was having a heart attack and questioned whether she was too young to have a heart attack, because she did not understand them. This would have been a perfect time for the therapist to address triggers for her anxiety and coping skills that she may have used in the past.
The client did identify having anxiety for her entire life, the therapist could have questioned if there was a certain life event that caused the initial anxiety when it first took place. She could have also asked if anyone else in her family has anxiety in order to gather information for a psychosocial assessment.
Susie was reassuring, affirming, and empathetic. In a brief amount of time she elicited the reason for this initial visit and uncovered a long term history of anxiety and possible depression. She showed enough engagement that the client feels relieved and hopeful. I would have wanted some indication that the client was not in my office because this long time anxiety/depression had really reached a point that the client might be having suicidal ideation. I would have asked more about that. As everyone has already mentioned, a mini mental health status and other assessments would follow.
I agree that Susie's empathetic and affirming approach was helpful to the client and perhaps made her feel more comfortable. Sometimes, especially on first visits, clients are so nervous and anxious that hearing a reassuring voice and allowing the clients to truly feel that they are in a non-judgmental and safe environment is not only important for the rapport building processes, but for client retention. These traits are truly indispensable.
I agree with everyone's comments thus far in regards to what Susie Social Worker did well and areas that she missed. I found her tone, questions and validation to be the first steps in creating a positive rapport with the client. I felt that she was validating and reassuring in many of her comments. I believe by completing a basic psycho-social assessment many of the gaps in information would be filled in. Also, determining the extent of her anxiety in terms of self harm, suicidal ideation or inability to function normally would be helpful to gain a better sense of safety or other ongoing issues that may contribute to the overall problem, such as substance abuse.
Overall, while short and not perfect, I enjoyed watching this clip. I liked the slow, even way that Susie Social Worker asked questions. I felt the way she phrased her questions and comments was very person centered and collaborative.
Christine George
P.S- I need to figure out a way to log out of my husband's g-mail account and set up one of my own. He is not reading anything on this blog, I promise!
I agree that more information needs to be gathered before a more formal diagnosis can be given to the client. I agree that asking about substance abuse will be vitally important as well, perhaps the client is self-medicating to help control the symptoms of anxiety or perhaps the anxiety is induced by substance use. This is a great point that I initially overlooked, assuming that the symptoms associated with her anxiety were organic since she reports experiencing them since childhood. Great thought!
Hi Christine and Rebecca, Substance use was not even on my radar. I realize I would have forms to follow, but that it the kind of thing I should already be thinking of- Thanks, Gail
I'll type this up AGAIN! (grumble grumble), but it may be briefer this time around.
Cartoon #1 did a few things right, as I see it. She A) showed empathy, saying "that must be really hard" or something like that, at one point. She B) asked about duration of symptoms (once anyway), and asked a follow up question about physical symptoms that revealed Cartoon #2 was having panic attacks. C) She made sure to normalize what #2 was going through, making sure to tell her "it's very treatable".
She did not, however, ask enough follow up questions about the symptoms, of the anxiety, including breezing over the mention that #2 has been having anxiety problems since childhood. She didn't follow up on the depression at all, not even to discover how severe it was or how long it had been going on...or the frequency of times when she had trouble getting out of bed. She didn't ask about suicidal ideation. And she didn’t ask questions about the immediate uptick in symptoms that led to #2 seeking treatment (presenting problem)
Then, of course, there's all the thousands of other questions that would be included in a true psychosocial assessment. Questions about #2's social situation, living situation, mental illness history, medical history, family, goals, etc. There's a lot more to cover in a beginning session.
You brought up a lot of good points in your post. While watching the clip and reflecting on it after, I like Susie Social Worker put more focus on the anxiety rather than the depression. During early appointments it is important to hear everything the client is saying to build rapport and highlight areas of further discussion. Thanks for bringing this up. I'm glad you are back to your sunny personality, I agree that computers, especially the Internet can be extremely frustrating.
Alice, I agree with you. When I watched the video the first time (yes I watched it more than once) my first response was, What is this what not to do. However when I watched again I focused more than just on what the SW was saying. I relaxed that a big part of what she was doing was trying to build rapport which is really important to do right form the beginning. Obviously none of us would hold a 5 minute session, unless the client decided to leave, and there would be much more follow up questioning but she really did a good job of making the client comfortable quickly.
You made a very good point, she did not even ask what the presenting problem was and did she decide to come in or was it suggested by someone else, which makes a huge difference.
I agree that if anxiety started in childhood, she should have asked about past treatment and then got releases to get the records from that time to help with understanding her history better. It is like putting together a puzzle and with this short interview, you would be lucky to build the puzzle border.
Amanda, I think you raised a good point in your reply. While, the SW didn't ask many of the highly pertinent questions needed, it's true that no one would hold a 5 minute session in real life. And she did do a pretty good job of building rapport with the client...as evidenced by the client saying how happy she was to be starting treatment at the end. So that's a very major thing that she did right.
Hi Alice, I think you bring up a good point about showing empathy and how important it is when establishing a therapeutic relationship with clients. I would agree that Sue Social Worker could have ask a lot more questions about frequency, duration and intensity of the clients symptoms. I also think it would have been really important to know more about supports in place.
I agree and think it is great that Susie social worker asked about physical symptoms. Often times anxiety may manifest in a variety of ways throughout the body so getting a good understanding of this is essential. I'm not sure I completely with her regarding completely ruling out any sort of medical diagnosis (ie: heart attack). and worry that this goes against the NASW code of ethics by making or ruling out a diagnosis that is out of her scope of practice. Other than that I certainly agree there were a variety of things she did and said which made the client feel safe.
It sounded like when the social worker was asking the questions, she seemed more interested in calming the client and in focusing on how what she was feeling was normal. I think that is a great place to start with a client it helps them feel more at ease with you and I understand that it was just really short example if this had been an hour long session I would likely have asked the following and then continued depending on the clients response:
These feelings of not being able to breathe or that you are having a heart attack,
How often do you feel this way?
How long does the feeling last?
Does it only happen at home?
Is it worse when you are out and running errands?
Can you think of a time you where able to stop the anxiety form rising to the level of feeling you were having a heart attack? If so what is it that you did that helped?
You said that you have had this issue since you were in grade school, have you ever seen anyone in the past?
How much does your depression or anxiety disrupt your daily routine/living?
We are off to a great start - with a tremendous amount of useful ideas to add to this brief snippet of an assessment. As another useful exercise, think of yourselves as future supervisors and review the entire script you have all shared here. How would you share this feedback with a new social worker? Consider tone of comments, use of strengths-based language, etc. No need for response here, just food for thought. If this conversation between Susie social worker and her client were a process recording that you were reading as a supervisor, would your comments be any different than those you offered above? Again, just food for thought. I am inviting this thought process as we will be sharing role play videos throughout the course, and while we will welcome critical feedback, the most useful feedback comes in a manner that is strengths-based. This will help us to take risks together, as skill-building progresses.
This is a place to engage in discussions about advanced generalist practice topics raised during the course. Students will enhance their developing practice skills through self-reflection and group discussion.
Hi all,
ReplyDeleteThe interaction was very, very brief and did not collect a lot of information. There was no Bio-Psycho-Social Assessment or safety assessment. There also seemed to be several missed opportunities to console the client and to ask additional questions. If a client presented to my office talking about the inability to get out of bed and crying I would complete a safety assessment before allowing her to leave. This seemed to be many missed opportunity to also build a relationship with the client, but Susie stuck to simple questions almost dismissing her reports of physical symptoms. I would have let the client take the lead and let her discuss the information she felt was important to why she was now seeking help.
If I was Susie the SW these are the additional questions I would ask.
Can identify times in your life when you didn't feel this way?
Can you identify what triggers your anxiety?
What things have worked for you in the past to manage those feelings?
Have you ever worker with a therapist or psychiatrist to address your anxiety or depression? If so, what coping skills did you learn that worked for you?
Why now, what’s different about your anxiety or depressions that has led you to seek help?
When was the last time you saw your doctor and had a medical screening? Are you taking any medications for depression or anxiety?
When was the last time you drank or used recreational drugs? Do you feel there is a connection with when you feel anxiety or depressed and when you are likely to use again?
Do you ever have thoughts of harming yourself? If so, what other ways have you thought of?
Do you feel safe returning home today?
Do you have a history of suicide attempts?
What motivated you to get out of bed on those really hard days? What else has worked for you in the past?
Do you have any family or social supports?
Absolutely, Jennifer! All great ideas. Sue social worker is a fun way to get you rolling. I expected you all might have some additional ideas. And a five minute role play will never offer as much as a real hour long assessment. Thanks so much for starting us off with all your great suggestions.
DeleteHi Jennifer,
DeleteGreat ideas. I agree with all of your questions. Since the client reports feeling anxiety since childhood, I think it is important to ask the client if anything has been helpful in managing these feelings. Even if coping skills have been negative such as substance abuse and/or self harm, it can be a great starting point and provide greater insight.
Christine George
After watching the lectures and video's I might avoid the "negative" questions and stay with strength based questions which I didn't ask many about.
DeleteI believe Sue social worker did a great job of attempting to understand the client’s presenting problem and what brought her into treatment. She asked good follow up questions regarding how long she has been experiencing anxiety as well as how she can tell she is anxious (sometimes this can get confused with other symptoms so it is important to verify). I also found it appropriate that she reinforced to the client that her anxiety is treatable and provided insight that they could work on the problem together.
ReplyDeleteIn order to get a better understanding of the client’s situation I would conduct a mental status (client’s appearance, facial expressions, movements, quality of speech, mood, feelings, risk assessment, orientation, etc). I might also begin a bio-psycho-social assessment with the client to get a better understanding of perhaps her history and other needs (ie: family structure, employment, housing, medical history, psychiatric history). This may lend some clues as to why she is experiencing this anxiety and help determine if she has received treatment for this sort of anxiety in the past. I always think it is important to ask clients in every session about suicidal or homicidal risk (which would fit into mental status), but I also like to ensure that their basic needs are being met (ie: food, clothing, etc). If a client is struggling with their most basic needs it may be appropriate to focus on those essentials which very well may be adding to some of their symptoms (ie: anxiety or depression).
More great ideas! Thank you, Rebecca! Assessment is a critical social work skill and many of you have had experience with this last year and in your employment situations. You are great resources for us. Keep the ideas coming!
DeleteHi Rebecca,
DeleteMental status exams are usually not my first go-to assessments (this could be because at my placement the doctors in admissions completes this before I meet patients). However, I do see where they can be valuable in assessing how symptoms and disorders are impacting a person's life. I believe we can get a lot of information in regards to a person's functioning and care of themselves by their appearance, mood, speech etc. Thanks for brining this us.
Christine George
Hi Rebecca,
DeleteIt's a good idea you brought up to do a little sleuthing about her living and/or social situation to figure out what could be the cause of her anxiety. Although she does say that she's had anxious episodes ever since childhood, that doesn't mean they're not being exacerbated acutely by an immediate problem in her life. And, if that's the case, then it's important for her counselor to know about it.
Rebecca, You bring up a good point that Sue Social Worker did do a great job in "normalizing" anxiety and reminding the client that its treatable.
DeleteBeyond confirmation that the prospective client has, one, come to the right place for services and, two, was comforted by Susie by the facts that anxiety and depression are very treatable, the assessment has hardly begun. It has only been established, in other words, that the prospective client is symptomatic of disorders that Susie's agency treats.
ReplyDeleteIn terms of assessment technique, which we've seen little of, Susie's demeanor/behavior strikes me as a harbinger of a medical model technique rather than a social worker's technique grounded in "person-in-environment."
To begin, I'd want to know how the client identifies herself and how she characterizes the contexts (i. e. home, work) that further define her being.
I thought that the therapist spoke with the client in a very calm tone. I found this to be a very brief assessment and the only information that I was able to gather from it was that she had anxiety.
ReplyDeleteI would ask if she has been in treatment in the past and if so was it beneficial for her and what things were beneficial?
I would ask her what motivated her to come in today to see me?
I would ask her who are her supports?
I would ask if she has ever harmed herself or others and if she currently felt safe.
Christine Mc.
The client described the anxiety almost as if she was having a heart attack and questioned whether she was too young to have a heart attack, because she did not understand them. This would have been a perfect time for the therapist to address triggers for her anxiety and coping skills that she may have used in the past.
The client did identify having anxiety for her entire life, the therapist could have questioned if there was a certain life event that caused the initial anxiety when it first took place. She could have also asked if anyone else in her family has anxiety in order to gather information for a psychosocial assessment.
Susie was reassuring, affirming, and empathetic. In a brief amount of time she elicited the reason for this initial visit and uncovered a long term history of anxiety and possible depression. She showed enough engagement that the client feels relieved and hopeful.
ReplyDeleteI would have wanted some indication that the client was not in my office because this long time anxiety/depression had really reached a point that the client might be having suicidal ideation. I would have asked more about that.
As everyone has already mentioned, a mini mental health status and other assessments would follow.
Hi Gail -
DeleteI agree that Susie's empathetic and affirming approach was helpful to the client and perhaps made her feel more comfortable. Sometimes, especially on first visits, clients are so nervous and anxious that hearing a reassuring voice and allowing the clients to truly feel that they are in a non-judgmental and safe environment is not only important for the rapport building processes, but for client retention. These traits are truly indispensable.
Hi All,
ReplyDeleteI agree with everyone's comments thus far in regards to what Susie Social Worker did well and areas that she missed. I found her tone, questions and validation to be the first steps in creating a positive rapport with the client. I felt that she was validating and reassuring in many of her comments. I believe by completing a basic psycho-social assessment many of the gaps in information would be filled in. Also, determining the extent of her anxiety in terms of self harm, suicidal ideation or inability to function normally would be helpful to gain a better sense of safety or other ongoing issues that may contribute to the overall problem, such as substance abuse.
Overall, while short and not perfect, I enjoyed watching this clip. I liked the slow, even way that Susie Social Worker asked questions. I felt the way she phrased her questions and comments was very person centered and collaborative.
Christine George
P.S- I need to figure out a way to log out of my husband's g-mail account and set up one of my own. He is not reading anything on this blog, I promise!
Hi Christine -
DeleteI agree that more information needs to be gathered before a more formal diagnosis can be given to the client. I agree that asking about substance abuse will be vitally important as well, perhaps the client is self-medicating to help control the symptoms of anxiety or perhaps the anxiety is induced by substance use. This is a great point that I initially overlooked, assuming that the symptoms associated with her anxiety were organic since she reports experiencing them since childhood. Great thought!
Rebecca
Hi Christine and Rebecca,
DeleteSubstance use was not even on my radar. I realize I would have forms to follow, but that it the kind of thing I should already be thinking of-
Thanks,
Gail
Urggh! Website ate my first post!
ReplyDeleteI'll type this up AGAIN! (grumble grumble), but it may be briefer this time around.
Cartoon #1 did a few things right, as I see it. She A) showed empathy, saying "that must be really hard" or something like that, at one point. She B) asked about duration of symptoms (once anyway), and asked a follow up question about physical symptoms that revealed Cartoon #2 was having panic attacks.
C) She made sure to normalize what #2 was going through, making sure to tell her "it's very treatable".
She did not, however, ask enough follow up questions about the symptoms, of the anxiety, including breezing over the mention that #2 has been having anxiety problems since childhood. She didn't follow up on the depression at all, not even to discover how severe it was or how long it had been going on...or the frequency of times when she had trouble getting out of bed. She didn't ask about suicidal ideation. And she didn’t ask questions about the immediate uptick in symptoms that led to #2 seeking treatment (presenting problem)
Then, of course, there's all the thousands of other questions that would be included in a true psychosocial assessment. Questions about #2's social situation, living situation, mental illness history, medical history, family, goals, etc. There's a lot more to cover in a beginning session.
Sorry about the irascibility of that intro to that post. I had computer issues. But I'm back to my usual sunny personality now.
DeleteYou all were astute in picking-up on Susie not inquiring about the client's safety (from self-harm). I was neglectful here as well.
DeleteHi Alice,
DeleteYou brought up a lot of good points in your post. While watching the clip and reflecting on it after, I like Susie Social Worker put more focus on the anxiety rather than the depression. During early appointments it is important to hear everything the client is saying to build rapport and highlight areas of further discussion. Thanks for bringing this up. I'm glad you are back to your sunny personality, I agree that computers, especially the Internet can be extremely frustrating.
Christine George
Alice,
DeleteI agree with you. When I watched the video the first time (yes I watched it more than once) my first response was, What is this what not to do. However when I watched again I focused more than just on what the SW was saying. I relaxed that a big part of what she was doing was trying to build rapport which is really important to do right form the beginning. Obviously none of us would hold a 5 minute session, unless the client decided to leave, and there would be much more follow up questioning but she really did a good job of making the client comfortable quickly.
Alice,
DeleteYou made a very good point, she did not even ask what the presenting problem was and did she decide to come in or was it suggested by someone else, which makes a huge difference.
I agree that if anxiety started in childhood, she should have asked about past treatment and then got releases to get the records from that time to help with understanding her history better. It is like putting together a puzzle and with this short interview, you would be lucky to build the puzzle border.
Christine McGovern
Amanda, I think you raised a good point in your reply. While, the SW didn't ask many of the highly pertinent questions needed, it's true that no one would hold a 5 minute session in real life. And she did do a pretty good job of building rapport with the client...as evidenced by the client saying how happy she was to be starting treatment at the end. So that's a very major thing that she did right.
DeleteHi Alice, I think you bring up a good point about showing empathy and how important it is when establishing a therapeutic relationship with clients. I would agree that Sue Social Worker could have ask a lot more questions about frequency, duration and intensity of the clients symptoms. I also think it would have been really important to know more about supports in place.
DeleteHi Alice -
DeleteI agree and think it is great that Susie social worker asked about physical symptoms. Often times anxiety may manifest in a variety of ways throughout the body so getting a good understanding of this is essential. I'm not sure I completely with her regarding completely ruling out any sort of medical diagnosis (ie: heart attack). and worry that this goes against the NASW code of ethics by making or ruling out a diagnosis that is out of her scope of practice. Other than that I certainly agree there were a variety of things she did and said which made the client feel safe.
Rebecca
Rather than me e-mail everyone individually, who still needs a partner for the role play activity? Any takers? I play nice with others... :)
ReplyDeleteChristine George
I still need a partner if you are still looking. I also play nice with others.
DeleteAmanda Snyder
It sounded like when the social worker was asking the questions, she seemed more interested in calming the client and in focusing on how what she was feeling was normal. I think that is a great place to start with a client it helps them feel more at ease with you and I understand that it was just really short example if this had been an hour long session I would likely have asked the following and then continued depending on the clients response:
ReplyDeleteThese feelings of not being able to breathe or that you are having a heart attack,
How often do you feel this way?
How long does the feeling last?
Does it only happen at home?
Is it worse when you are out and running errands?
Can you think of a time you where able to stop the anxiety form rising to the level of feeling you were having a heart attack? If so what is it that you did that helped?
You said that you have had this issue since you were in grade school, have you ever seen anyone in the past?
How much does your depression or anxiety disrupt your daily routine/living?
Yes Amanda, you are getting at the duration, intensity and frequency of her anxiety.
DeleteChristine had the right idea, I think. I'm still looking for a partner for the roleplay. Anyone still looking for a partner?
ReplyDeleteI need a role play partner, Alice.
DeleteOk. Sounds good. :-)
DeleteWe are off to a great start - with a tremendous amount of useful ideas to add to this brief snippet of an assessment. As another useful exercise, think of yourselves as future supervisors and review the entire script you have all shared here. How would you share this feedback with a new social worker? Consider tone of comments, use of strengths-based language, etc. No need for response here, just food for thought. If this conversation between Susie social worker and her client were a process recording that you were reading as a supervisor, would your comments be any different than those you offered above? Again, just food for thought. I am inviting this thought process as we will be sharing role play videos throughout the course, and while we will welcome critical feedback, the most useful feedback comes in a manner that is strengths-based. This will help us to take risks together, as skill-building progresses.
ReplyDelete