The Purpose of This Chapter Is to Help Learners Develop Proficiency in the Assessing Skills

Chapter 8

Assessing

ASSESSMENT IS A FUNDAMENTAL PROCESS IN PROFESSIONAL SOCIAL WORK PRACTICE(Compton & Galaway, 1999, pp. 271-295; Cowger, 1994,1996; Gilgun, 1999; Hudson & McMurtry, 1997; Meyer, 1993, 1995; Perlman, 1957, pp. 164-203; Richmond, 1944; Ripple, 1955; Zastrow, 1995, pp. 75-104). When the exploration process has progressed well, you and the client have gathered andbegun to reflecton a substantial amount of relevant information about the person-issue-situation. You have traced the origin and development of theissue and identified factors that might be associated with its occurrence. You have learned about aspects of the person, issue, and situation in the present and the past, and even considered various scenarios in the future. You have identified strengths and resources of various kinds (e.g., competencies, social support, successes, and life lessons) - some of which might be useful in addressing issues and achieving goals. During the assessment phase, you - usually in collaboration with the client - try to make sense of this information so you can help the client address the issue or issues that have emerged. You analyze how the person and situation influence the issue of concern, and vice versa. Most importantly, you consider how the issue of concern might be addressed, often drawing on strengths and resources within the person or the environment.

Understanding gained from these reflective and analytic processes usuallyleads toan emerging focus or direction for you and your client. The assessment represents thebasis on which to establish a clear and detailed contract for your work together. This chapter (see Box 8.1) helps learners develop proficiency in the primary social workskills commonly involved in the assessment process: (1) organizing descriptive information, and (2) formulating a tentative assessment.

BOX 8.1

Chapter Purpose

The purpose of this chapter is to help learners develop proficiency in the assessing skills.

Goals

Following completion of this chapter, learners should be able to demonstrate proficiency in the following:

*Understanding the functions of assessment

*Organizing descriptive information

*Formulating a tentative assessment

*Ability to assess proficiency in the assessing skills

Assessment involves both lifelong learning and critical thinking as you bring your professional knowledge and the client's experience together in a process of reflection, analysis, and synthesis. Using theoretical and empirical knowledge within the context of a person-and-situation perspective, you assess individuals, families, groups, organizations, or environments. You may use conceptual or assessment tools of various kinds.You might reflect on diagrammatic representations such as a family genogram, an ecomap, or a timeline (refer to Chapter 2). IT IS IN THE USE OF THESE AIDS THAT OUR USE OF SOCIAL WORK SKILLS BECOMES INVALUABLE.

You might consider the results of scales or questionnaires such as the Social Support Appraisals Scale (see Chapter 2) or any of the hundreds of valid and reliable instruments that might pertain to an issue of concern (Corcoran & Fischer, 2000a, 2000b). You might examine a phenomenon in relation to a set of criteria or guidelines that have been derived from research studies or validated protocols. For example, in assessing the relative risk of child abuse, you might consider empirical factors such as those summarized by Herring (1996). Among others, certain conditions tend to be associated with a greater risk of child abuse: history of child abuse/neglect reports, parent abused as a child, youthful parent, single parent or extended family household, domestic violence in household, lengthy separation of parent and child, substance abuse by parent or caretaker, impairment (e.g., physical, intellectual, psychological) of the child, and impairment of the parent or caretaker (Brissett-Chapman, 1995, pp. 361-362). Using factors such as these as a guide, the worker thoughtfully considers the information learned during the exploring phase to determine the risk of child endangerment. The outcome of the assessment may powerfully affect, for better or worse, the well being of a child and family. The consequences of both false positives (where the worker concludes there is high risk but the true danger is low) and false negatives (where the worker concludes there is low risk but the true danger is high) can be serious - in some cases, genuinely life-threatening.

Although social work assessments tend to have much in common, the specific form may vary considerably according to practice setting. For example, a gerontological social worker might refer to government guidelines in helping to determine whether a nursing home has adequate physical facilities and sufficient social stimulation to meet the basic needs of an elderly client. A psychiatric or clinical social worker might refer to criteria published in the Diagnostic and Statistic Manual (DSM-IV-TR) (American Psychiatric Association, 2000) to help determine if a client might be depressed and, if so, how seriously (Williams, 1995). A social worker serving in a crisis and suicide prevention program might use guidelines to estimate a distraught client's risk of suicidal action as low, moderate, or high.

Of course, certain kinds of issues commonly surface in almost all practice settings. Among others, violence toward self or others, child physical and sexual abuse, and substance abuse are likely to emerge as concerns wherever you serve. All social workers, therefore, need to be alert to their possible presence. Indeed, some agencies make it standard operating procedure to assess for substance abuse, child abuse and domestic violence, and risk of violence toward self or others. As a social worker doing so, you might consider various sources. The DSM-IV-TR, for example, contains these criteria for substance dependence and substance abuse (Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, Copyright 2000 American Psychiatric Association, pp. 197-199):

CRITERIA FOR SUBSTANCE DEPENDENCE

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

(1)Tolerance, as defined by either of the following:

(a)A need for markedly increased amounts of the substance to achieve intoxication or desired effect

(b)Markedly diminished effect with continued use of the same amount of the substance

(2)Withdrawal, as manifested by either of the following:

(a)The characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)

(b)The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

(3)The substance is often taken in larger amounts or over a longer period than was intended

(4)There is a persistent desire or unsuccessful efforts to cut down or control substance use

(5)A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

(6) Important social, occupational, or recreational activities are given up or reduced because of substance use

(7) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

CRITERIA FOR SUBSTANCE ABUSE

A.A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

(1)Recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance related absences, suspensions, or expulsions from school; neglect of children or household)

(2)Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

(3)Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

(4)Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

B.The symptoms have never met the criteria for Substance Dependence for this class of substance. (American Psychiatric Association, 2000, pp.197-199)

Although primarily a manual of psychiatric disorders, the DSM-IV-TRaddresses several dimensions and contains materials that social workers and their clients may find pertinent. Axis III, for instance, includes "General Medical Conditions" that might relate to a psychiatric disorder. Such conditions, of course, might also affect various social problems as well. Furthermore, Axis IV refers to "Psychosocial and Environmental Problems" and includes the following subcategories:

• Problems with primary support group
• Problems related to the social environment
• Educational problems
• Occupational problems
• Housing problems
• Economic problems
• Problems with access to health care services
• Problems related to interaction with the legal system/crime Other psychosocial and environmental problems (American Psychiatric Association, 2000, p. 32)

Problem-focused assessment is often complemented with rapid assessment instruments of various kinds (Corcoran & Fischer, 1987, 2000a, 2000b; Fischer & Coreoran, 1994a; Hudson, 1982). In the case of substance abuse issues, instruments such as the CAGE Screening Test for Alcohol Dependence, the Michigan Alcoholism Screening Test (MAST), or the Drug Abuse Screening Vest in conjunction with other information, can be used as aids for determining, for instance, whether a client might be physically addicted, perhaps indicating a need for detoxification in a hospital setting. Judgments of this nature and magnitude require perspective, objectivity, and extremely well developed critical thinking skills. Your judgments also require a greatdeal of lifelong learning because of the changing nature of "knowledge" on which assessment criteria are based.

The CAGE Screening Test is a test for

a)alcholosism

b)dementia

c)alzheimer’s

d)age identification

e)correct answer not given

HOW MANY STUDENTS KNOW SOMEONE WHO IS IDENTIFIED AS PERSON WITH AN ALCOHOL PROBLEM?

THE PURPOSE OF THIS EXERCISE IS TO ASSIST YOU IN FULFILLING THE REQUIREMENTS OF YOUR FINAL PAPER FOR THIS COURSE.

EXERCISE ON DEALING WITH ALCOHOL OR DRUG ABUSE ISSUES

NOTE BENE:ATTEMPT IN THE PROCESS OF ASKING THE QUESTIONS, TO PROVIDE SOME REFLECTIVE RESPONSES (AS FOUND IN THE PREVIOUIS CHAPTERS OF COURNOYER) TO THE STUDENT CLIENT’S ANSWERS.

1. ASK THE QUESTIONS TO YOUR PARTNER THAT ARE FOUND IN CAGE AND MAST

1. DETERMINE IF THE PERSON IS DEEMED TO HAVE A SUBSTANCE ABUSE PROBLEM

1. TALK OVER YOUR OBSERVATIONS WITH THE STUDENT CLIENT

1. REVERSE ROLES AND DO THE ABOVE THREE QUESTIONS

1. COME BACK AS A LARGER CLASS TO DISCUSS YOUR OBSERVATIONS.

Axis V of the DSM-IV-TR (American Psychiatric Association, 2000) includes a Global Assessment of Functioning (GAF) scale through which a client's "psychological, social, and occupational functioning" may be rated "on a hypothetical continuum of mental health-illness" (p. 34) and several provisional tools including a Defensive Functioning Scale (pp. 807-813), a Global Assessment of Relational Functioning (GARF) Scale (pp. 814-816), a Social and Occupational Functioning Assessment Scale (SOFAS) (pp. 817-818), and an Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes (pp. 897-903).

Although the DSM-IV-TR is extremely well known and widely used by practitioners from several professions, some social workers may find it useful to incorporate the) person-in-environment (PIE classification system (Karls & Wandrei, 1994a) in assessment processes. The PIE approach provides practitioners - presumably with the input and perhaps the participation of clients - an opportunity to classify or code problems within four dimensions or factors (Karls & Wandrel, 1994a, pp. 1-6):

*Factor I: Problems in Social Role Functioning

*Factor II: Environmental Problems

*Factor III: Mental Health Problems (classified with DSM-IV-TR codes)

*Factor IV. Physical or Medical Conditions (coded according to the International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM])

Problems in Factor I-Social Role Functioning (e.g., family roles, interpersonal roles, occupational roles, special life situation roles) may be identified and then classified and coded by type (e.g., power, ambivalence, responsibility, dependency, loss, isolation, victimization) as well as by the severity of the problem, its duration, and the client's copingability (Karls & Wendrei, 1994a, pp. 4, 7-22).

Problemseverity is rated on a six-point scale where 1 = no problem and 6 reflects a catastrophic level.

123456

NO MODERATE CATASTROPHIC

PROBLEM

Duration is evaluated via a six-level system where l = more than five years and 6 = two weeks or less. Problems of more recent origin and shorter duration receive a higher numerical number. Client coping ability is rated on a six-point index where 1 = outstanding coping skills and 6 = no coping skills (Karls& Wandrei, 1994a, pp. 35-37).

The practitioner may then use the classifications within Factor II-Environmental Problems, to identify those situational conditions that affect or perhaps are affected by the identified problems in social role functioning (Factor 1). Environmental problems are categorized according to the following systems (Karls & Wandrei, 1994a):

1. Economic/basic needs

2.Education and training

3.Judicial and legal

4.Health, safety, and social services

5.Voluntary association

6.Affectional support

Each of these major categorical systems (e.g., Education and Training) contains subcategories (e.g., Discrimination), and each subcategory contains specific problems or conditions (e.g., Disability Discrimination). Once an environmental condition or problem has been identified, its severity and duration are determined and coded (Karls & Wandrei, 1994a, pp. 23-34).

A social worker and client using the PIE Classification Manual might, for example, identify the following problem classification (among others):

+Factor I: Parent Role Problem, ambivalence type, very high severity (5), six months to one-year duration (3), somewhat inadequate coping skills (4) [1120.5341

*Factor II: Absence of Affectional Support, high severity (4), six-months to one-year duration (3) [10101.43] (Karls & Wandrel, 1994a).

The PIE classification system (Karls & Wandrei, 1994a) has generated considerable interest among social work academicians and researchers (Karls & Lowery, 1997; Karls & Wandrei, 1992a, 1992b, 1994b, 1995; Williams, 1994; Williams, Karls, & Wandrei, 1989). Social work practitioners, however, appear to be less intrigued. Many may not be aware of the system, and others, especially those in health and mental health settings, may not see the valueof additional classification beyond the DSM-IVTR or the ICD-10. The potential utility of the PIE classification scheme may only become apparent in years to come when epidemiological and demographic studies establish the incidence and prevalence rates of various social role functioning and environmental problems. Like the DSM-IV-TR, the PIE classification system is primarily problem-focused in nature. To be truly useful to helping professionals and consumers, effective intervention strategies must be established for each problem classification or diagnosis. Indeed, such is the case for several psychiatric disorders included within the DSM-IV-TR. Ithas taken many years of clinical research for safe and effective medicines for conditions such as schizophrenia or psychosocial treatment protocols for disorders such as agoraphobia. You may expect much time to pass before effective prevention or interventionservices can be established for many of the social role functioning problems and environmental conditions included within the PIE ClassificationManual (Karls & Wandrel, 1994a).

During the last decade or two, many helping professionals have become concerned that exclusive or excessive focus on problems may interfere with clients' motivation and impede progresstoward resolution. In addition, several scholars have questioned the assumption that detailed exploration of clients' personal and social histories and in-depth understanding of the contributing causes of psychosocial problems are necessary to effectively resolve those problems. Partly because of these concerns, professional helpers have become extremely interested in concepts and perspectives related to strengths, assets, resiliencies, and solutions.

Dozens of books, book chapters, and articles have been published on the topic of strengths-based practice or the strengths-model of social work practice (Clark, 1997; Fast & Chapin, 1997; Wisthardt, 1997; C. A. Rapp, 1998; R. Rapp, 1997; Saleebey, 1997, 1999, 2002). Indeed, Saleebey proposed the development of a diagnostic strengths manual (Saleebey, 2001) to counter-balance the problem-focused perspective reflected in the American Psychiatric Association's Diagnostic and Statistical Manual (DSM).

Locating, enhancing, and promoting resilience (Greene, 2002; Masten, 1994; Norman, 2000; Walsh, 2003) and hardiness (Kamya, 2000; Lifton, Seay, & Bushko, 2000; Maddi, Wadhwa, & Haier, 1996) have generated similar interest, as has solution focused or solution-oriented practice (Baker & Steiner, 1996; Berg, 1994; Berg & De Jong, 1996; Berg & Reuss, 1998; Birdsall & Miller, 2002; Corcoran & Stephenson, 2000; De Jong & Berg, 2002; deShazer, 1988; LaFountain & Garner, 1996; Lee, 1997; Lipchik, 2002; MacKenzie, 1999; Metcalf, 1995; Miller, Hubble, & Duncan, 1996; O’Hanlon, 2003; O'Hanlon & Weiner-Davis, 1989; Zimmerman, Jacobsen, Maclntyre, & Watson, 1996).

Another theme or trend in psychosocial services involves the dimension of motivation enhancement - particularly as it relates to the "transtheoretical" or the "stages of change" model (Budd & Rollnick, 1996; Miller & Rollnick, 1991, 2002; J. M. Prochaska, 2000; J. 0. Prochaska, 1999; Prochaska & DiClemente, 1982; Prochaska, Norcross, & DiClemente, 1994; Rollnick, 2002; Rollnick & Miller, 1995). According to the transtheoretical perspective, long-term change in the person-issue-situation generally tends to proceed sequentially in six stages (Prochaska et al., 1994, p. 39):

*Precontemplation

*Contemplation

*Preparation

*Action

*Maintenance

*Termination

Prochaska et al. (1994) assert that none of these stages may be skipped. Although the process may be spiral rather than linear in nature, each stage is eventually addressed.

Precontemplation is the firststage of change and is characterized by ambivalence, uncertainty, disinterest, or denial. For example, suppose you had agreed to help an unemployed, wheelchair-bound client find a job. When you first contact a prospective employer who has never employed someone who used a wheelchair, you might anticipate a precontemplative response. Despite the Americans with Disabilities Act, the employer could be quite reluctant to seriously consider the request. As a social worker, your first step toward change would be to help the employer to the next stage - contemplation.

Contemplation is the second stage of the change process. This stage is characterized by information-gathering, reflection, and analysis. The possibility of change is considered. There may even be a general sense of direction or a vague plan. Consider the situation of your wheelchair-bound client and the "reluctant employer." Suppose you provide written materials that outline the benefits of a diverse workforce and describe businesses that became successful after employing disabled workers. When the “precontemplative employer" reads and considers those materials, and thinks about the possibility of hiring a wheelchair-bound person, you would begin to see signs of contemplation and reflection. Unfortunately, thinking about change in general terms does not usually produce it. In trying to serve your client, you encourage the employer toward the preparation stage.