MOVING BEYOND ASSESSMENT

MOVING BEYOND
ASSESSMENT
A PR ACTICAL GUIDE FOR BEGINNING
HELPING PRO FESSIONAL S

Melissa D. Grady
and
Eileen A. Dombo

1
1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America.
© Oxford University Press 2016
First Edition published in 2016
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.
You must not circulate this work in any other form
and you must impose this same condition on any acquirer.
Library of Congress Cataloging-​i n-​P ublication Data
Grady, Melissa D.
Moving beyond assessment : a practical guide for beginning helping professionals /​Melissa D. Grady
and Eileen A. Dombo.
pages cm
Includes bibliographical references and index.
ISBN 978–​0 –​19–​936701–​6 (alk. paper)
1. Social service—​Practice. 2. Social service. 3. Counselor and client. I. Dombo, Eileen A. II. Title.
HV10.5.G695 2016
361—​dc23
2015030193
9 8 7 6 5 4 3 2 1
Printed by Sheridan, USA
We dedicate this book to our students and our clients, past, present,
and future. We have learned and continue to learn a great deal from
them, and are honored to be part of their learning and growing
experiences. Thank you to our families, without whose unwavering
support over the years our work would not be possible. And finally,
to our colleagues who continue to inspire us with their dedication to
improving our world around us.
CONTENTS

1. Introduction 1

2. What to know before you start 4

3. Cultural and identity issues in practice 21

4. Your role and relationship with your clients 29

PART I BEGINNINGS

5. The first session 41

6. Assessment 50

7. Asking the difficult questions: What to ask and how to respond 63

8. Assessing the safety of the client 73

9. Assessing safety of others in relation to the client 84

PART II PLANNING AND IMPLEMENTING
INTERVENTIONS

10. Evidence-​based practice and how to use research in treatment planning 95

11. Role of theory in social work practice 107

12. The middle phase of treatment 123

13. Planning for change and setting goals 135

PART III ENDING WITH CLIENTS

14. Endings 147

15. Evaluation of practice 158

PART IV ONGOING ISSUES FOR CONSIDERATION

16. Supervision 171

17. Technology and social media 183

18. Beginning knowledge of the brain and its functions 191

19. Final thoughts 201

References 205
Index 217

viii • Contents
MOVING BEYOND ASSESSMENT
 CHAPTER 1

INTRODUCTION

A client walks into the room. He looks sad, disheveled, and hopeless.
He has come to you for help—​to “fix the problem.” He states he wants you to help him
“make his life better and to feel better.” Your job, or so you feel, is to alleviate his struggles
and instill in him hope and a sense of empowerment, right? Or so you ask yourself.
Most new practitioners feel an overwhelming sense of pressure to know what to do
in every practice situation. Whether it is meeting with an individual client in an agency
setting, engaging with a family for a home visit, or working in the community, new prac-
titioners often feel that they ought to know exactly what to do, even at the beginning of
their training. People choose to enter professions like social work, psychology, counseling,
nursing, medicine, and other helping professions because they want to help people and, in
turn, make the world better and more just. Yet, the feeling of being at a loss regarding how
exactly to accomplish those goals comes quickly, often right at the beginning of graduate
school. Good intentions only go so far. In addition to having good intentions and a pas-
sion for and commitment to the work, practitioners need to have skills and knowledge and
be able to use them appropriately and discriminately depending on the situation at hand.
We want to emphasize from the start of this book that you will develop the capacities
described through a lifelong learning process. We know you have heard that before, and
that does not help you now as you are starting out and need some tools to succeed today.
Yet, we feel compelled to mention it here because often beginning practitioners feel frus-
trated by the pace of this learning process and want to gain knowledge more quickly. Part
of what makes working with people so engaging is their complexities. When these com-
plexities are then paired with individual, family, group, or community circumstances, it
can feel overwhelming to believe that you will ever have adequate skills and knowledge to
help create a change in someone’s life or community. However, with each iteration of your
training, you will continue to gain more knowledge. By pairing your knowledge with an
increased understanding of how to mobilize and utilize this ever-​g rowing set of skills, you
will feel more confident in your professional capacities.
This book was designed to be part of the beginning phase of this lifelong learning pro-
cess. It is written to assist new helping practitioners feel less anxious and more prepared to
approach and work with the clients and communities they desire to help. It is not designed
to be a comprehensive guide to your training as a practitioner but rather to help you take
the initial steps in your own journey.
As practitioners and professors, we have received numerous requests from students
and novice practitioners to find a book that is clear and easy to understand and helps them
feel more prepared for the initial stages of working with clients. As such, we have written
each chapter to be a reference guide that is easily readable and accessible. Combined, we
have over 30 years of practice experience plus over 15 years of teaching social work gradu-
ate students about practice, theory, and research. In writing this book, we used knowledge
from our own practice experiences in conjunction with years of working with graduate
students to address here what beginning practitioners need at the initial stages of working
with clients. The book is meant to be user friendly and to address many of the issues of
concern for beginning practitioners, as well as address other practice-​related issues that
they have yet to ponder. This book is primarily intended to help practitioners who will be
working in direct practice settings rather than in communities or macro practice. While
some of the concepts and principles may apply, this book is aimed at helping those begin-
ning practitioners who will be working with individuals, families, or groups. In addition,
although we include a chapter on the diagnosis of mental health disorders, this book is
meant to extend beyond mental health or clinical practice. We hope that the book will be
applicable to multiple practice settings.
We believe that before individuals can even start to think about working with clients
in a direct practice way, the first step is to think about developing their professional style
and way of working. Therefore, Chapter 2 addresses the working alliance as well as the
professional self and issues related to taking care of the self in doing this work. Chapter 3
focuses on exploring and understanding the role of cultural and identity issues in practice.
Chapter 4 addresses the context in which practice occurs and understanding how the set-
ting guides your role. Following Chapter 4, the book is divided into three sections. The
first section focuses on assessment and the beginning stages of working with clients. The
chapters in this section address the first session, assessment, the importance of asking
difficult questions, and safety assessment for both the client and others involved with the
client, including the worker.
The second section focuses on issues related to preparing for and implementing inter-
ventions with clients. It is designed to help you prepare thoughtfully for your work with
clients, including the use of the evidence-​based practice process, the role of theory in
treatment planning, preparation of a treatment plan, preparation for termination, and how
to create an ongoing assessment process of your work with clients. In other words, how
will you know whether what you are doing with your client is working? This section also
includes chapters on how to work with clients in the “middle phase” of an intervention.
It is not designed to be a toolkit on how to work with every client, and it will not provide
examples of practice models. These issues are beyond the scope of this book. This section
is meant to provide some guiding principles and to address some basic issues related to
intervention.
Finally, in the third section we address the changing landscape of practice. The chap-
ters in this section address finding a supervisor and getting the most out of your supervi-
sion; provide considerations related to the use of technology and social media; and provide
a beginning understanding of some of the biological, medical, and neurobiological issues

2 • Moving Beyond Assessment

related to practice. These chapters provide some guidelines on these complex issues that
will certainly evolve over time as the world changes—​and you change as a professional.
We conclude the book with some parting advice and tools that will be useful as you
begin your journey as a helping professional. We include well-​established resources in
these areas with the hope that they will remain helpful to you throughout your career.
However, we encourage readers to remain aware of new and evolving resources in their
particular areas of practice.
In the end, we hope that this book provides you with a bit more confidence and knowl-
edge as you enter the first stages of your training and career. Working with clients pro-
vides an exciting journey but can be a bit daunting at the same time. Our intention is
to help keep the excitement about the work alive, simultaneously helping to reduce the
anxiety so that you can be present and available to your clients as you join them on their
own journey, which has the potential to enhance your own as well. After all, this journey
is what keeps us engaged in this work.

Introduction • 3
 CHAPTER 2

WHAT TO KNOW BEFORE

YOU START

It is the first day of your internship or the first day of your new job in social
work or a related helping profession. You are getting ready to begin a new stage of your
career. You may have a number of questions about what you should wear or how you
should introduce yourself. You may also have a number of concerns about what others
will think of you or how you will answer tough or personal questions from your clients.
In addition, there may be other issues that you may not have even thought of that are
important to consider, such as how this work will have an impact on you or change you
in some way. This chapter is designed to help you think through some important pre-
liminary issues so that you are as prepared as possible when you start this new phase of
your career.

THE DEVELOPMENT AND CARE

OF THE PROFESSIONAL SELF
For most of us, when we are with certain individuals or groups we act in a particular way;
we share more or less compared to when we are with others, we let down our guard or put
it up, and we even dress in a particular way based on who we are with at the time. In each
situation, we have a way that we act or present a different “self,” which is often dependent
on a variety of factors.
A professional social work setting is no different, as there are different ways that we
should and do act in such contexts. Social workers need to present a professional self in
their work with clients and in their interactions with colleagues. While this statement
may seem obvious, in our experience as professors and supervisors, the concept of a
professional self is not always adequately explored by social work students. As such, we
believe it is essential that future social workers think through what it means to have a
professional self and what this self would “look like” for them. We believe there are several
essential components to a professional self, namely: dress and physical appearance, how
to work with interdisciplinary teams and other professionals, communication factors, and
consideration of how the National Association of Social Workers’ (NASW, 2008) Code of
Ethics informs how social workers should behave as professionals.

DRESS AND PHYSICAL PRESENTATION

Whether someone has completed training or is still in the midst of it, social workers must
present themselves professionally. We do not in any way mean to imply that social workers
or trainees should run out and buy an extensive or expensive wardrobe. It also does not
mean that your personal style needs to be altered significantly. We simply mean that the
way you dress should reflect the respect you have for your role and for those with whom
you work. Table 2.1 provides some general guidelines to consider as you are thinking
through how to present yourself in a professional setting.
Remember that everything you have on your body is a form of self-​disclosure and may
be a topic of interest to your clients. Items such as jewelry (e.g., a cross or star-​of-​David
necklace, a wedding/​commitment ring), a tattoo, and piercings might all be topics that
are of interest to your clients. We are in no way suggesting that you do not wear them
or show them; we are simply encouraging you to be prepared to hear questions about
such items. We suggest that you speak to your supervisor before you start about what is

TABLE 2.1: Dress Guidelines

Guideline Explanation
Clean clothes—​not clothes that May communicate to the client that you cannot take care
are stained or have marked holes of your own clothes, so how will you take care of them?
For women: skirts that are at least This is especially if you will be sitting down on the
to the knees floor, such as with young children.
For women: ensure that the tops Many social workers will be bending over paperwork or
you wear do not show inside doing other related activities, and you should wear a
your shirts when you bend over camisole or closer-​fi tting clothing if this applies.
Be cognizant of the setting with Professional does not have to mean fancy or
regard to the expense of the expensive. Be conscious of what message it sends
clothing or other accessories to clients in your setting to appear in expensive
clothing or jewelry.
Wear clothes that consider safety In some settings, safety may be a factor. Consider
shoes that allow for easy running or clothes that are
not too loose and could be grabbed.
Avoid clothing with messages Clothes that communicate your affiliation with a
on them particular group other than the agency should be
avoided, as it is a form of self-​disclosure and could
send unintended messages to the client(s).
Avoid clothing inappropriately Tight-​fi tting clothes can be distracting and too
tight revealing.
Wear clothing that is consistent Use your colleagues as your guide in terms of
with those of the other workers appropriate clothing. Observe others and try to
follow their lead as much as possible.

What to Know Before You Start • 5

appropriate attire for your setting and to plan how to respond to clients when they do ask
questions about your personal appearance. It is best to be clear about the expectations and
norms before you start and to feel prepared for such questions or comments from clients
ahead of time. When deciding what to wear, whether it is clothing, jewelry, or other items,
reflect on the balance between the importance of the item to you and the potential of its
distraction of others from the work at hand. This process can help you discern which items
are essential to your authentic presentation of self and which you may want to choose to
bring out in a different setting.

WORKING WITH INTERDISCIPLINARY TEAMS

The majority of practice settings will require social workers to work with profession-
als from other disciplines. These professionals could be individuals with similar train-
ing as you (i.e., a psychologist or other mental health worker) or completely different
training from you (i.e., a vocational trainer or teacher). Regardless of the composition
of the team, there are two key points we want to make about social workers’ roles on
these teams.
The first point is that social workers should be active members of the team. Our mes-
sage here is that if you do not speak up, then neither the profession nor the needs of your
clients are represented. It may seem intimidating to speak up in a group with others who
appear to be or who actually are more experienced or educated than you. However, the
fact that they have more experience does not mean that they should be the only members
to have an opinion or a perspective. It is possible that the social worker knows something
that the other team members do not. It may be that the client has shared something
with the social worker that he or she has not shared with the rest of the team (i.e., the
client does not like taking his medicine because it makes him feel nauseous). In addition,
some teams may be focused on the struggles or deficits of the client and not as focused
on the strengths or capacities of the client. Because social work training emphasizes the
strengths perspective, social workers can bring this important perspective to the team.
For these reasons, we encourage you to be a vocal presence on the teams in which they
are involved.
The second point we want to make is that, as team members, social workers should
present themselves as professional and competent. Again, just as with dress, this state-
ment might appear obvious. However, we have some specific points we feel are important
to consider. The first is that while we believe social workers should be a presence on the
team, they should provide relevant feedback as opposed to speaking only to have some-
thing to say. Therefore, be thoughtful about what information you want to share before
you share it. If possible, take some time to plan what you want to say so that your thoughts
are organized and clear.
Next, with whatever ideas you have that you want to present, provide a rationale for
those ideas. It is important that these opinions be based on research, theory, client feedback,
or some other credible source. There have been studies that have reported that social work-
ers are perceived by their colleagues as not having a strong basis for their opinions and have
even been referred to as “airy-​fairy” in their approach to working with clients (McCracken &

6 • Moving Beyond Assessment

Marsh, 2008, p. 134). Therefore, it is important that social workers explain the rationale for
their professional opinions and that these points are based on credible sources.

COMMUNICATION
One of the ways of expressing and presenting the professional self is through oral and
written communication. With written communication, social workers may use multiple
methods to communicate with colleagues, other professionals, clients, and family mem-
bers, such as paper or electronic means. We spend more time in Chapter 17 discussing
social media and other issues related to technology, but we want to discuss a few issues
here concerning communication in general and to offer some general guidelines to follow
with regard to how to communicate in a professional manner.

WRITTEN COMMUNICATION
What is essential to remember about written communication is that once you write it, it is
available for everyone to see. Check with a supervisor about rules concerning communi-
cation. Otherwise, remember the following:

• Anything posted online can be sent to anyone or anywhere else.

• Write everything as if you know that the client will be reading it.
• If writing is not a strength of yours, make sure you have someone review/​edit your
work. You are representing the social work profession, and the work should be
professional. Anything you write can be part of a permanent record that could be
around for years.
• In any form of written communication, use a professional style of writing, such
as opening with “Dear Ms. Jones” or “Dear Dr. Jones.” Remember the tone of
e-​mails should be as if you were writing a formal letter and not just an e-​mail to
an acquaintance.
• Think about the clients and whether they are more likely to respond to one form of
communication compared to another.

ORAL COMMUNICATION
• Be sure that with oral communication you ask others to repeat back to you what
they have heard because often your meaning can be misunderstood.
• It is often prudent to follow up on oral communication with a written note in the
file or email to document that the communication took place and the message that
was conveyed.
• Speak clearly and avoid fillers such as “um” and “like” as they detract from the
message and the professionalism of the communication.
• Use formal communication unless instructed to address the person informally.
• Be aware of your nonverbal communication, which may contradict your message.

What to Know Before You Start • 7

 HOW THE NASW CODE OF ETHICS INFORMS
THE PROFESSIONAL SELF
Finally, social workers on teams and in professional settings need to be always cognizant
that they are representing a profession that has a core mission and values. Therefore, the
comments and opinions expressed by the workers on teams and in meetings should be
consistent with the profession’s values and ethics. In addition, the actions of the worker
should be in keeping with the principles that guide the profession, such as maintaining
boundaries and the roles to which they are assigned. We have unfortunately been on
teams where some of our social work colleagues, in their desire to help their clients,
have made suggestions that cross boundaries (e.g., by the workers offering to provide
a service outside of his or her role). We have also witnessed our colleagues describe a
conversation to other professionals in which they have disclosed confidential informa-
tion from the client—​indicating that they do not uphold confidentiality agreements.
Therefore, we strongly recommend that the readers be familiar with the NASW (2008)
Code of Ethics to better understand the behaviors associated with our professional
standards. We encourage you to review them as soon as possible if you have not already
done so. They can be easily accessed online (https://​w ww.socialworkers.org/​pubs/​
code/​default.asp).

USE OF SELF
Throughout your professional career, you will most likely hear the term use of self. The
definition is somewhat elusive, in that it is used differently to describe various aspects of
how you use yourself in your work with clients. These aspects can refer to personality or
behaviors, such as sense of humor, body language, and others (Dewane, 2006; Edwards &
Bess, 1998). In these instances, the phrase is used to capture what many people think of
the art of the work you do with clients (Cameron, 2014; Graybeal, 2014). Just like a cook,
musician, or painter, for example, the personal style influences how you execute whatever
task you are doing with your clients. In this way, you will be developing your own style or
fine-​t uning the “instrument” you will be using in the relationship with the client: your-
self. (See Chapter 4 for more information on the relationship.) If you think about different
medical care doctors you have had, there may be some who had a great “bedside manner”
compared to others who did not. Those who you liked may have shared a bit about them-
selves, leaned in when they talked to you, asked you questions that appeared to go beyond
your “presenting problem,” or had other characteristics that you noticed. Two different
providers can be providing the same “intervention,” but their styles may be quite differ-
ent; these examples represent one interpretation of the use of self.
Another way of defining use of self is derived from the theoretical orientation that is
used by the social worker. Different models of intervention in micro, mezzo, and macro
social work as well as different modalities of treatment (i.e., individual, group, or family
interventions) describe the role or stance of a social worker in those contexts. We discuss
more about how different theories inform our work with clients in Chapter 11. For now,

8 • Moving Beyond Assessment

it is important to know that, depending on which theory you are using to help inform
your work with a client, theory may guide you to be slightly different with the client than
if you were using a different theory. For example, let us compare two different individual
models. One might have you focus more on your reactions to the client and what those
reactions tell you about the client and then purposefully and with careful intent articulate
to the client those reactions to help facilitate change. Another model might have you be
more of a coach to the client, with your focus on teaching skills. Using this model, your
reactions to the client are irrelevant to the skill-​building focus and would not be shared
at any time with the client. Each of those stances asks something different of the worker.
These differences are driven primarily by the underlying assumptions of the model and
what is assumed will facilitate change.
For us, the phrase use of self is a combination of both of these definitions. Social work-
ers need to attend to, notice, and use their personalities to engage with clients. As social
workers evolve professionally, their own styles and comfort levels with what they bring to
the relationship with clients grow and change (Schneider & Grady, 2015). Good supervi-
sion can be a useful tool in helping newer social workers reflect on how their own styles
have an impact on all clients as well as with certain subgroups. This topic is covered in
more detail in Chapter 16. In addition, social workers need to be aware of the assumptions
of the model they are using and how those assumptions lead to a particular stance or style
of working with clients. Both of these definitions or descriptions of the use of self are
essential for workers to attend to in their work.

SELF-​AWARENESS
A key factor in the ability to purposefully use ourselves with clients is our own level of
self-​awareness. One of the most critical aspects needed for a competent social worker is
being self-​aware. If we are unaware of how we come across to others, such as how our
sense of humor can be “off-​putting,” our discomfort with eye contact, or the tone of our
voice, then we will not be cognizant of how those personality styles or traits are affect-
ing our clients. We also need to know our own triggers for when we might be upset or
offended or when we might be more likely to cross a boundary with a client. We need to
be aware of which clients we are more likely to avoid versus those we eagerly seek out.
We need to think about what we gain by doing this kind of work with clients and what
toll it might be taking on us. Without self-​awareness, we can make professional judg-
ment errors that can have lasting consequences, both for ourselves and for our clients
(Safran, 2011).
There are many ways to gain self-​awareness. Some social workers have advocated for
all students studying for the master’s in social work to participate in therapy (Mackey &
Mackey, 1993) as a way to have future workers gain some insight regarding who they are
and what their vulnerabilities are as well as their strengths. However, requiring social
work students to attend therapy has garnered criticisms, including the associated costs
and that some students may identify a preference for a path to self-​awareness (Mackey &
Mackey, 1993). Other methods to increase self-​awareness besides therapy include journ-
aling, spiritual guidance or counseling, use of supervision, or personal relationships. We

What to Know Before You Start • 9

are not advocating for any one particular pathway. What we are advocating is for every
reader to find an ongoing useful method that enhances their own self-​awareness so that
the clients are receiving care from social workers who use themselves in a professional,
cognizant, and intentional way.

SELF-​DISCLOSURE
Also tied to use of self is the use of self-​d isclosure with clients (Burkard, Knox, Groen,
Perez, & Hess, 2006; Dewane, 2006; Edwards & Bess, 1998; Katz, 2003; Schneider &
Grady, 2015). Self-​d isclosure can take many forms. The most commonly thought of form
is the worker sharing some type of information about him-​or herself with the client
(Burkard et al., 2006; Dewane, 2006; Edwards & Bess, 1998; Katz, 2003; Schneider &
Grady, 2015). However, as we discussed previously in this chapter, self-​disclosure can also
take the form of the jewelry or tattoos that a worker shows. In this section, we focus on the
first type of self-​d isclosure. This focus is not to dismiss the importance of being thought-
ful about what you wear on your body or other forms of self-​disclosure, such as the car you
drive or the bag you carry. We encourage all readers to be cognizant of what messages are
being sent to clients and colleagues by how we present ourselves. In our work with stu-
dents and recent graduates, we have found the most challenging aspects of self-​disclosure
tend to be centered on information that they are being asked to or choose to share about
themselves. Therefore, we have chosen to focus on this aspect of self-​disclosure.
What appears to be most challenging in our experience is that in most every other
relationship (professional or personal) a way to connect with another person is to relate
something about ourselves to the other. For example, when meeting someone who is from
a different part of the country, it is common to reflect on your own experiences, or lack
thereof, and enter into a dialogue about these experiences in relation to the others’. Or,
if someone is frustrated with a colleague, it is socially acceptable to share a similar story
to demonstrate to the other that you can relate because of a similar experience. While
both of these scenarios may be focused on relatively mild topics, there are three important
points we want to make regarding why these seemingly innocuous approaches may not be
appropriate in a professional social work context.
First, by talking about yourself, you are taking the focus off the client. The social
worker is not and should not be the focus of the work; the client is the focus of the work—​
always. We are there to connect, engage, and empathize. We are not there to be friends or
to have a conversation that implies mutuality. While you want to do as much as you can to
eliminate the power differential that will inevitably exist between you and your client, this
relationship is not mutual as only one person’s needs in the room should be addressed, and
those are not the worker’s.
The second point is that by disclosing some information about yourself, it can poten-
tially set up an expectation by the client that you will share more. If you answer one ques-
tion and then refuse to answer another, the client may wonder: What has changed? What
is it about the current question that you are uncomfortable sharing? This line of thinking
again shifts the focus away from the client and to you, shifting the direction of inquiry to
the worker rather than to the client.

10 • Moving Beyond Assessment

 Finally, it is important to consider that once that information is shared, you cannot
take it back. There is a confidentiality agreement often made between you and the client,
but this agreement is one directional. You, as the worker, cannot disclose information about
your client, but there is no rule that the client cannot share what you have said to others.
We have had colleagues, for example, who discovered that information the worker had
chosen to share with the client ended up on a blog that the client had written. Other col-
leagues and clients saw the blog and now that information about the worker was on the
Internet, able to be found with a simple Google search.
We are not trying to state that social workers should never disclose any information.
Social workers often do share information. In some settings, there is more of an expec-
tation that information will be shared (such as your religious faith if you are part of a
faith-​based center). It is also more common in some cultures to share information about
yourself, especially if two individuals are from the same culture. However, any informa-
tion that is shared should be done purposefully, thoughtfully, and always in the service of
the client. It is important to be thoughtful about what impact a piece of information has on
the clients themselves, as well as the work itself. Without knowing why the client wants to
know the information or how your sharing the information will further the work, disclos-
ing information could be potentially damaging. A phrase that you will hear throughout
this book to help you think through your choices is: Why are you doing this particular
thing with this particular client at this particular time? If you cannot clearly identify the
reason, then it is likely a good idea to pause and reflect some more in supervision. When
it doubt, don’t!
I (M.D.G.) was in a peer supervision group several years ago when a colleague was
describing an encounter she recently had with a new client. (I have received permis-
sion to share this story in the book, but her name and the name of the client are with-
held for confidentiality reasons.) The client came to see her about receiving therapy
as she was struggling with issues concerning infertility and was looking for some help
to manage her grief and other feelings. She was interviewing several different ther-
apists in the area (which is common and we both encourage it), and the client was
asking each therapist about whether they had children. My colleague was the only one
who chose not to answer the question. She explored with the potential client what she
hoped to gain from having that information, how it would affect her knowing that a
therapist did or did not have children, how she felt it would enhance the work together,
among other questions. The client was shocked that she did not respond, experienced
it as odd and withholding, and left angry. Much to my colleague’s surprise, this client
returned to her and asked to start treatment with her. What the client realized was
that, based on what she had learned about the other therapists’ parental status, she was
spending much of her energy and thoughts on what she imagined was going on in the
lives of those other therapists. With my colleague, however, because she did not know
the parental status, the work felt more about her and not about her fantasies about the
therapist.
We think this example is a powerful one in helping to understand how a piece of infor-
mation once shared can have a profound impact on the client. Therefore, self-​disclosure
should only be done after thoughtful consideration. Again, our rule is “when in doubt,
don’t.”

What to Know Before You Start • 11

 There are ample ways to buy time so that you can think more about a question,
possibly consult with a supervisor, and then return to the client with a thoughtful
response. Some useful phrases are the following:

• Tell me what would be helpful to you if you knew this information?

• I hear that this piece of information is something that you want to know. Before
answering your question, I would like to think more about it and get back to you
the next time I see you.
• Can you tell me a bit more about how knowing this information would help you?

It can be common for clients to ask you about your own personal experiences related
to something they have gone through themselves, such as substance abuse or sexual
abuse. Often, in those situations they want to know if you will “get it.” Will you under-
stand their experience? However, what is always important to remember is that even if
you have had “on paper” the same type of background or history, this apparent similar-
ity in no way can be assumed to be the same experience. This statement can also be said
for people who come from the same family who have lived through the same event. If
you think about your own family and a critical event that occurred in your family, your
experience of that event and your reactions to and memories of it will most likely be
different from your other family members’. Therefore, we encourage you not to disclose
whether you have or have not had a similar background because your story is in many
ways irrelevant for understanding what that event or life story meant to your clients or
what significance it plays in their current life. In some cases, when clients know that the
practitioner had a similar experience, the clients may begin to have feelings of pressure
or even a sense of failure as they compare their lives to yours. Of course, these com-
parisons are based on their own assumptions and perceptions, which may or may not
be accurate. Regardless of their accuracy, the focus again shifts away from them to the
social worker.
Your experience can inform your questions and possibly help you to be more empathic,
but it is always important to keep in mind that your job is to understand the clients’ expe-
rience so that you help them in the best way possible. How you use your own history to
inform your work is a critical piece of the concept of use of self and one that will evolve
over time as you develop as a social worker (Schneider & Grady, 2015).

ROLE OF THE WORKER

One final aspect of the use of self is the role you have with your client. Social workers
have many different roles with clients, including advocates, brokers of services, clinicians,
investigators, supervisors, hospice or medical discharge planners, intake/​triage workers,
community organizers, and many more. We expand on the role of the worker in Chapter 4.
However, here we want to emphasize that with each of these roles comes a different set
of expectations as well as ways that we use ourselves. For example, if you are only going
to be working with a client one time as a triage/​intake worker, your goal is to focus on
getting the information that will most help you identify the needs of the client so you can

12 • Moving Beyond Assessment

determine the most appropriate type of service for that client. In contrast, if you are work-
ing in a clinical role with the client, you may be more focused on building a relationship
rather than being as purposeful in fact gathering on the first service.
In both of these scenarios, it is essential that social workers conduct themselves in a
professional manner and use their personality in ways that help make the clients feel at
ease and comfortable. However, the pacing of the time with the client, the types of ques-
tions that are asked and even details like whether you are in front of a computer or holding
a clipboard are all aspects of how the worker presents and uses him-​or herself.
Given the variety of roles that social workers can play, it is essential that workers who
are new to an agency or to a position within the agency ask supervisors and other col-
leagues about their styles in engaging with clients. How do they engage with clients given
their roles? Can they give some examples of times an interaction with a client was tricky?
What happened? How did they handle it? Depending on the role those individuals have
with clients, they will respond differently. Therefore, it is important that workers new
to that setting have a clear understanding of the expectations, scope, and limitations of
their roles.

THE IMPACT OF THE WORK ON

THE SOCIAL WORKER
Milton Erickson used to say to his patients, “My voice will go with you.” His voice did.
What he did not say was that our clients’ voices can also go with us. Their stories become
part of us—​part of our daily lives and our nightly dreams. Not all stories are negative—​
indeed, a good many are inspiring. The point is that they change us.
​M ahoney, 2003, p. 195

The work that you will do as a social worker will have an impact on you in profound ways.
We hope and have every expectation that the work will have mainly positive impacts as
you grow and develop as a professional. However, both of us have worked a significant
amount in settings and with clients where trauma or other profoundly painful events
have affected clients. We have experienced changes in our own lives as a result of this
work and believe it is essential for social workers to use their self-​awareness to notice
such changes and address them should they begin to negatively impact their ability
to stay resilient and engaged in the work. For example, I (M.D.G.) have worked with
adolescents who have sexually abused other children. At one time, I was facilitating a
treatment group for female adolescents who were adjudicated for molesting children.
In this group, four of the five girls had been babysitting at the time of their offense. As a
result of this experience (and my other work with this population), I have always been
particularly wary of babysitters with my own children. For example, I have always felt
more comfortable with them going to a group care setting where there are multiple
eyes rather than having a babysitter, which for me feels too scary. However, many of my
friends have always preferred the nanny option as they feel their children are cared for in
their homes and obtain more one-​on-​one attention. Of course, rationally I know that the

What to Know Before You Start • 13

vast majority of caregivers are safe and will not molest children. I know this statistically
and factually. However, my experiences in the field have changed my perspective, and
I behave differently as a result.

COMPASSION FATIGUE
It is important for social workers and other professionals to pay attention to the different
reactions that they might experience in the field. There is a large body of literature that
describes the various ways that practitioners may react when working in challenging set-
tings. We provide more information in the Resource Guide as we do not do justice here to
the literature and resources on this topic. This chapter focuses on the concept of compas-
sion fatigue (CF), which is a phrase used to capture the toll that the work can take on the
worker (Figley, 1999). CF can be seen as the strain experienced by the therapist to remain
empathic and connected to clients who are relating their traumatic stories.
There are many ways that a social worker can begin to experience CF. For some prac-
titioners, hearing the stories of their clients can shift their perspective, as I (M.D.G.)
described previously in this chapter regarding my own practice experiences. This shifting
is referred to as vicarious trauma (VT) and refers to a shift that can occur when practi-
tioners have repeated exposure to “clients’ traumatic experiences [that can] cause a shift
in the way that trauma counselors perceive themselves, others and the world” (Trippany,
Kress, & Wilcoxon, 2004, p. 31). In other words, as you begin to hear the stories of your
clients, your views of the world change (McCann & Perlmann, 1990). Maybe you feel less
safe or maybe you feel guilty with your increased awareness of privilege or maybe you
become more cynical about the level of humanity in the world.
Another path toward CF is when a practitioner has experienced secondary traumatic
stress (STS). For those who experience STS, their symptoms or reactions closely resem-
ble those who have experienced the trauma firsthand. These symptoms or reactions are
similar to those who have shown signs of post-​traumatic stress syndrome, which might
include jumpiness, hyperawareness or hypervigilance of their surroundings, flashbacks,
difficulties sleeping, or intrusive memories or dreams (Figley, 1999). The changes as a
result of VT are primarily focused on the cognitions of the worker, whereas STS reactions
mimic trauma reactions and the biological and psychological symptoms of having been
exposed to trauma via their clients.

BURNOUT
Compassion fatigue can then be the result of the worker’s experience with either VT or
STS, leading to a high level of fatigue and struggles to remain present with clients. Many
individuals are familiar with the term burnout. It is often used to describe someone who
appears not to care anymore about their job, does not seem engaged, and is cynical or
apathetic at best regarding what happens as a result of their work. This view of burnout
is similar in those who are in helping professions and is seen to be “a result of the general
psychological stress of working with difficult clients versus having a traumatic reaction

14 • Moving Beyond Assessment

to a specific client-​presented information” (Trippany et al., 2004, pp. 31–​32), such as can
occur with VT and STS. Also, burnout generally happens gradually, whereas VT and STS
can have a sudden and acute onset. Burnout also does not tend to have the changes asso-
ciated with VT, such as changes in trust or intrusive memories, yet it is possible that burn-
out can result from VT and STS. Burnout can be the result of the ongoing stress involved
in helping those in challenging situations, which is often paired with feeling hopeless or
helpless to do more.

COMPASSION SATISFACTION
What is also important to remember is that there are also some positive outcomes that
come from this work. Compassion satisfaction (CS) refers to the positive experiences of
being in a helper role (Stamm, 2002). If working with people who have had traumatic
experiences or major life difficulties was so hard all the time, no one would do it. There is
a sense of reward or accomplishment that comes with serving those in need. What draws
us to social work or other helping professions is a desire to see people overcome obstacles
or transcend traumatic experiences, or to help communities reach their potential. Caring
brings a level of satisfaction from these experiences, and helping others carries rewards
that serve as protective factors against CF (Stamm, 2002). CS is the reason we keep doing
our jobs, even when it is hard or overwhelming, because we see growth, healing, recovery,
and success in our clients.

THE IMPORTANCE OF SELF-​A SSESSMENT

By now, you are probably catching on that a critical theme throughout this chapter is the
need for self-​awareness, which includes an awareness of how we affect clients and how
the work directly affects us. Just as with the other areas we have discussed previously, it
is important for workers to have self-​awareness regarding how the work may be having an
impact on us in our professional lives as well as how those reactions spill into our personal
lives. Conducting self-​assessment concerning how your work is affecting your professional
and personal lives should take place on an ongoing basis, even when you feel “fine.” Using
standardized tools or checking in with colleagues and supervisors about your work should
be integrated regularly into your professional life. In settings where supervision is not the
place to address the impact of the work, think about finding a “self-​care buddy” with whom
you can meet regularly and talk to about ways to take care of yourself in the work. To help
you get started, the Resource Guide at the end of the chapter lists some useful resources for
assessing yourself and where you can find more information on these topics.

WAYS TO SUPPORT SELF

Remaining resilient in this work requires daily attention to self-​care. If you wait until your
vacation or until you have enough money for a spa day, it will be too late. Daily attention

What to Know Before You Start • 15

 General Guidelines for Protecting Self Against VT, STS,
TABLE 2.2:
Burnout, and CF
•  Remember that treating trauma patients is not for everyone.
•  The issue is managing VT rather than totally avoiding it.
•  Emphasis should be on early identification and treatment, reducing the long-​t erm
negative impact of VT.
•  Interventions need to be multilevel and should not be left up to the individual.
•  A psychotherapist or helper should not feel ashamed or guilty about
experiencing VT.
•  The attitude should be on validating and normalizing such reactions.
•  Reframe VT as a sign of being a committed and a sensitive therapist.
•  Nurture awareness, balance, and connections.

Source: Adapted from Meichenbaum (2006).

to what may seem obvious—​eating regular meals, sleeping well each night, and leaving
work on time—​is important as a first step. Each person will need to find personal strate-
gies to help prevent or minimize these potential negative reactions to the work with cli-
ents. There is no one way. However, Table 2.2 offers some guidelines from Meichenbaum
(2008) that we have adapted regarding his discussion of VT.
Also, we encourage social workers to consider the importance of looking at multiple
levels of their work. Implementing a multilevel self-​care model is one way of accomplish-
ing this goal (Dombo & Gray, 2013). This model requires looking at self-​care on all lev-
els: individual, departmental, and organizational. In this model, self-​care is not only the
worker’s issue or responsibility but also the responsibility of every member of the orga-
nizational system. In this multilevel model, organizational leadership is responsible for
exploring how the environmental factors play a role in worker health, program directors
and supervisors explore ways team meetings and other group forums can be used to nor-
malize the effects of the work and provide education and support, and finally the worker
is provided with education and tools to address the individual experiences of CF or VT
(Dombo & Gray, 2013).

ENDING ON AN UPLIFTING NOTE

While we have just described a number of potential challenges that can arise from your
work as a helping professional, we want to end this chapter with some words of encourage-
ment. As practitioners, we have found that we are inspired, awed, amazed, and profoundly
moved by our work. We have found this work to be challenging emotionally and intel-
lectually, and through these experiences, we have grown personally and professionally.
Neither of us can imagine any other career where we would have the privilege of hearing
someone’s story, being part of their journey of reaching whatever goal that they may have,
and seeing changes occur in all levels of society as a result of social work efforts.
We truly believe that social work’s perspective of valuing the complexities of our
clients’ lives does have the risk of being overwhelming, as our profession considers
poverty and issues of social justice that have an impact on our clients along with

16 • Moving Beyond Assessment

mental health and family dynamics. Yet, because social work attends to these multi-
level issues, we are trained to and can intervene in multiple arenas in our society. We
are not limited to any one level (micro, mezzo, or macro) of social work practice. This
unique perspective of social work is a perfect way to remain balanced in our profes-
sional lives. We can work one-​on-​one with clients and then also think about systemic
issues and work with teams to create those changes. As a result of this diversity of roles
and ways to intervene, not only can social workers diversify their work to remain fresh
and invigorated, but also this diversity provides opportunities for us to make changes
in a multitude of ways.
We are excited that you have chosen social work as your profession. We hope that by
thinking through some of these issues before you start your professional career or near its
beginning, you will have the opportunity to be as prepared as possible so that you have a
long and fulfilling career as a social worker. It is a rewarding profession, and we hope that
you will gain as much from it as we have.

CHAPTER 2 RESOURCE GUIDE: ASSESSING

YOUR SELF-​CARE (RICHARDSON, 2001)
This self-​care assessment is designed to measure how well you are balancing your own
needs with the needs of those you serve. It is recommended you reassess yourself on a
regular basis and use the results to adapt your self-​care plan as needed. It is designed
to be used as a tool to help you gain AWARENESS about your own needs and limita-
tions, maintain BALANCE between your work self and personal self, and deepen your
CONNECTION to this work.
Use the following scale to rate the frequency with which you engage in these self-​care
activities:

5 = Frequently
4 = Occasionally
3 = Rarely
2 = Never
1 = It never occurred to me to do this!!

A. PHYSICAL SELF-​C ARE

_​_​_​_​_​Eat regular meals
_​_​_​_​_​​Eat healthy foods
_​_​_​_​_​​E xercise
_​_​_​_​_​​Get regular medical care
_​_​_​_​_​Take time off when sick
_​_​_​_​_​​Get massages
_​_​_​_​_​​Do fun physical activities
_​_​_​_​_​Take time to be sexual

What to Know Before You Start • 17

 _​_​_​_​_​​Get enough sleep
_​_​_​_​_​​Wear clothes you like
_​_​_​_​_​​Take vacations or day trips
_​_​_​_​_​​Get away from telephones
_​_​_​_​_​​Other:_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_

B. PSYCHOLOGICAL SELF-​C ARE

_​_​_​_​_​​Make time for self-​reflection
_​_​_​_​_​​Engage in your own therapy
_​_​_​_​_ ​​​​Journal
_​_​_​_​_​Read about topics unrelated to work
_​_​_​_​_​Try not to be in charge
_​_​_​_​_​Decrease stressful experiences
_​_​_​_​_​Listen to your inner experiences
_​_​_​_​_​Let others see different aspects of you
_​_​_​_​_​Practice receiving from others
_​_​_​_​_​Be curious
_​_​_​_​_​Say no to extra responsibilities
_​_​_​_​_Other:_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

C. EMOTIONAL SELF- ​C ARE

_​_​_​_​_​Spend time with those whose company you enjoy
_​_​_​_​_​Stay in touch with old friends
_​_​_​_​_​Give yourself affirmations and praise
_​_​_​_​_​Love yourself
_​_​_​_​_Revisit favorite books and movies
_​_​_​_​_​Identify comforting things
_​_​_​_​_Allow yourself to cry
_​_​_​_​_​Find things to make you laugh
_​_​_​_​_​E xpress your outrage via social action
_​_​_​_​_Play with children
_​_​_​_​_​Other:_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

D. SPIRITUAL SELF- ​C ARE

_​_​_​_​_​Spend time in nature
_​_​_​_​_​Connect with a spiritual community
_​_​_​_​_​Be open to inspiration and hope
_​_​_​_​_​Connect to the nonmaterial
_​_​_​_​_​Be present, not the presenter

18 • Moving Beyond Assessment

 _​_​_​_​_​Identify what has meaning for you
_​_​_​_​_​Meditate/​pray/​sing
_​_​_​_​_​Spend time with children or animals
_​_​_​_​_​Have experiences of awe
_​_​_​_​_​Contribute to causes you believe in
_​_​_​_​_Read literature that inspires you
_​_​_​_​_​Other:_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

E. WORKPLACE AND PROFESSIONAL SELF-​C ARE

_​_​_​_​_​Schedule breaks in your workday
_​_​_​_​_​Take time to chat with colleagues
_​_​_​_​_​Make quiet time to complete work
_​_​_​_​_​Identify projects that are rewarding
_​_​_​_​_​Set limits with clients and colleagues
_​_​_​_​_​Balance work/​caseload
_​_​_​_​_​A rrange a comforting workspace
_​_​_​_​_​Get regular supervision
_​_​_​_​_​Negotiate your needs
_​_​_​_​_​Have a peer support group
_​_​_​_​_​Develop nontrauma areas of professional interest
_​_​_​_​_Other:_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

A SPIRITUAL PRACTICE OF MEDITATION

FOR ADDRESSING VICARIOUS TRAUMA
By infusing spiritual practices into one’s self-​c are, the social worker can address the
reactions to the work in a simple, portable, and inexpensive way. This process focuses
on taking off what has been taken in from your time with the client. It is a three-​step
process, using meditation, to let go of or not take on the reactions to the client’s pain
and suffering. It can be done briefly between appointments to be ready for your next
client or in a longer meditation after the day is done. We have developed this specific
meditation based on the loving kindness meditation practices used by many medita-
tion teachers.
Practice 1 addresses compassion for self as “helper” in trauma work. As the clinician
becomes the vehicle for client healing, he or she must use mindfulness as a relational con-
cept, where the clinician models self-​compassion through personal practice and behav-
iors. Practice 2 surfaces reactions to what the client brought up in session or the clinician’s
reactions to the client. It provides an opportunity to cleanse the mind and emotions from
the interaction. Practice 3 addresses the clinician’s own issues that surface through trauma
work. Using this meditation, one can focus on letting go of ego attachments to the role of

What to Know Before You Start • 19

“helper” or status in the community. It helps one let go of resentments held from feeling
“put upon” by others’ pain and suffering. This enables clearer focus on what is gained from
helping trauma survivors, how the work is purposefully and mindfully engaging. Created
using breathing meditation (Salzberg, 2011b) and adapted from the Buddhist practice
of loving kindness meditation (metta), the meditation we offer for addressing VT is as
follows:
Find a calm place, without distractions. This can be a certain chair, or a corner of
a room. Sit comfortably. At first, simply observe the breath. Notice it going up and
down, in and out. Take a few cleansing breaths. Notice “I am breathing in”; “I am
breathing out.”
After a minute or two, slowly say the first phrase of the compassion meditation to your-
self. Do this on an “in breath.” Breathe in and out contemplating the phrase. You may want
to repeat it.
After several breaths focused on the first phrase, continue on to the next phrase of the
compassion meditation. In a similar manner, slowly say each phrase of each practice. As
you end the practices, take a few cleansing breaths to end the meditation.

Practice 1: Compassion meditation.

“May I be gentle with myself in my work.”
“May I be attuned to those I help.”
“May I forgive the imperfect nature of my work.”
Practice 2: Letting go meditation.
“May I let go of my client’s pain.”
“May my client know peace.”
“May I let go of my reactions to my client’s pain.”
Practice 3: Reflection mediation.
“May I heal from my own pain and suffering.”
“May I give thanks for being able to do this work.”
“May I transcend my ego attachment to my role/​my client’s progress.”

Excerpted from “Engaging Spirituality in Addressing Vicarious Trauma in Clinical

Social Work: A Self-​Care Model,” by E. A. Dombo and C. Gray, 2013, Social Work and
Christianity, 40(1), 89–​104.

20 • Moving Beyond Assessment

 CHAPTER 3

CULTURAL AND IDENTITY

ISSUES IN PRACTICE

I n helping relationships, the differences between practitioners and clients

are often the elephant in the room. This chapter addresses ways to bring these differences
into the relationship in an effort to enhance the working alliance, build rapport, and
deepen your understanding of your clients’ lived experiences. We discuss how elements
of difference and similarities can impede or enhance the work and offer some guidelines
to help overcome these barriers. Practitioners are encouraged to honor difference, not
make assumptions when either differences or similarities are noted, and learn about their
clients through a stance of not knowing.
To operate from a stance of not knowing is to utilize the techniques and tools dis-
cussed in the assessment section related to ethnographic interviewing and to approach
each client as a unique person with his or her own distinctive identity. This approach
allows practitioners to engage in culturally competent work through curiosity about cli-
ents’ unique lived experiences. The goal of the curiosity is to create the opportunity for
clients to share the following with the practitioner: the clients’ identity, experiences of
oppression, and meaning made of these experiences.

INCREASING YOUR AWARENESS

OF OPPRESSION AND POWER
To truly understand your clients’ worlds, you need to gain a deeper understanding of their
experiences of oppression and powerlessness and the potential impact of those experi-
ences on all aspects of the bio-​psycho-​social-​spiritual domains. Throughout the course of
your professional education, you have probably heard the term isms (e.g., racism, sexism)
used to describe the multiple dimensions of identity that form the basis of marginaliza-
tion and discrimination (Corneau & Stergiopoulos, 2012). Virtually every dimension
of a person’s identity is subject to norm/​other categorizations that leave some identities
more privileged than others (Rosenblum & Travis, 2008). This idea sets forth the notion
that there are identities that are considered the norm by mainstream culture; therefore,
those are categorized as not the norm are considered different or other. If you reflect on
the US culture, people in the norm categories are those who are Caucasian, male, Judeo-​
Christian, able bodied, mentally healthy, and so on. Therefore, those who fall in the other
categories are people of color, women, people with physical disabilities, people with men-
tal illnesses, and the like. Most of the individuals, families, and communities with whom
you will work experience multiple forms of oppression and marginalization based on
race, ethnicity, socioeconomic status, religion, gender expression, sexual orientation, age,
disability, mental illness, and other dimensions of identity. A crucial aspect of how we
work with our clients is our own self-​awareness regarding power and how we view and
value difference (Schmitz, Stakeman, & Sisneros, 2001; Spencer, 2008; E. Williams &
Barber, 2004).

OPPRESSION
One way to think about the experience of oppression is to think about freedom. Is the
client able to act out of free will, or are restrictions placed on the client due to some dimen-
sion of the client’s identity? Is the client able to accomplish the personal goals he or she has
set out, or are their seemingly insurmountable obstacles in the way? Oppression limits a
person’s ability to act freely by closing certain options to them (Dybicz, 2010).
For example, imagine you are working with a client named Joe who is a 34-​year-​old
man from Nicaragua. He immigrated to this country when he was in his teens and was
later diagnosed with schizophrenia. Joe has been living in a halfway house since being
released from prison. His previous arrest was for assault with a deadly weapon while
under the influence of drugs and alcohol. He is attending Narcotics Anonymous (NA)
meetings to try to stay clean and is striving to adhere to his medication regimen to man-
age the symptoms of his mental illness. Your job is to help Joe find a job and housing.
Joe has been on several interviews but has not been selected for a job. In the interviews,
he has been asked if he has “papers” to prove he is in this country legally, has been told
that his English is not good enough for the job, and has been asked questions about his
criminal background and mental health status that revealed that the interviewer was
not comfortable with Joe. On multiple occasions, you have found an apartment for him,
but when he showed up to look at it, the landlord told him that the apartment was no
longer available.
One way to look at Joe’s inability to find a job and a place to live is to explore what he
does in the interviews and give him skills to improve. Another way to look at it is through
the lens of oppression. Is Joe being discriminated against because of some aspects of his
background and identity? To help Joe, it will be important to explore how these experi-
ences feel to him and the meaning that he is making of them. If we focus solely on enhanc-
ing his functioning and performance in job interviews, we miss the larger sociocultural
experience of discrimination. When we are able to help Joe see that he is not “failing” in
these tasks but rather the lack of success is due to discrimination, the formulation of the
problem shifts.

22 • Moving Beyond Assessment

 Rather than viewing the lack of success as a personal failure, you see that discrimination
is infused in the societal structures related to employment and housing. This shift in under-
standing creates a counterstory to explain what is happening (Dybicz, 2010). The narrative
shifts from being a problem with Joe to a societal problem. While this understanding does
not help Joe get the job or the apartment on a particular day, it does show Joe that you do
not blame him for not reaching these goals. In addition, you can communicate that you and
he will plan together to shift the focus of your work to overcome these obstacles. It puts you
and Joe on the same team: squaring off against oppression and discrimination.

POWER
Power is another force in our society that, while often invisible, has a strong influence on
our lives. Most students and novice practitioners do not feel as if they have much power in
their work settings. More likely, in your setting, you feel more like the least powerful person
there. However, to your client, you have a great deal of power. You have power by virtue of
your role, knowledge, and access to resources. Although it may be hard for you to believe
that you do in fact have this power, we encourage you to think about times when you have
gone to a provider, anyone from a mechanic to a physician, for a service. In these cases, you
are often dependent on the other for knowledge of the problem, the solutions and skills for
resolving it, and information about how much the service will cost. The provider holds the
power to help you or not, as well as to tell you how much such help will cost.
One of the reasons we love our profession is that we recognize the existence of power
within the helping relationship. In addition, we work hard to simultaneously minimize
the power imbalance while using our power (i.e., knowledge, skills, resources) to help
clients achieve their goals. To assist in this process, we recommend that you have a direct
discussion with your client about power and oppression in the life of the client, as well
as in the working relationship, which will open honest discussion about ways to work
together (E. Williams & Barber, 2004).

ADDRESSING ISSUES OF OPPRESSION

AND POWER IN PRACTICE
When initiating a helping relationship, it is important to place the awareness of the expe-
rience of oppression and power front and center in your mind and include a desire to
understand through the lens of the client. This awareness relates directly to our ability to
work competently across cultures because “cultural interaction is a fluid process that is
dynamic” (Lee, 2011, p. 190). When we use the term culture, we refer to a range of identi-
ties, recognizing that families, communities, individuals who share a particular identity,
and other groups have their own sense of a culture. Simultaneously, we must always keep
in mind that each individual within that group has an experience that is unique to him or
her and may be outside any perceived norm for that group. Therefore, it is essential in our

Cultural and Identity Issues in Practice • 23

work that we consistently seek to understand the individual’s experiences and percep-
tions rather than impose our own.
This understanding of the clients’ experiences develops and evolves over time as
we communicate our desire to understand them more fully. It also comes through a
greater level of trust as clients opt to share more with us. We cannot emphasize enough
that while you may have received information about the experiences of a certain popu-
lation from journals, books, movies, or other sources, keep in mind that the client will
have his or her own personal experience that is unique. If you attempt to show that you
“understand” based on your academic learning or stereotypes you hold rather than
communicate that you truly want to understand the clients’ lived experience, you risk
alienating them.
Often, what prevents us from truly understanding our clients is the reality of being in
a subjective state in cross-​cultural work. The client is an “ethnic stranger” to us, and this
causes anxieties and discomforts that can lead to problems forming a strong working alli-
ance to reach the client’s goals. How we feel about clients is informed by our

• Culturally based life values (influenced by our culture)

• Theoretical beliefs and practices (shaped by academic training)
• Emotionally charged prejudices (rooted in personal experiences)
• Biases about own ethnic identity (shaped by family of origin and personal
experiences) (Perez Foster, 1999)

Our self-​awareness about these factors allows us to see when they are getting in the way
of the work. When we can take the perspective of those we are working with, we are less
likely to act out of our own biases (Yoon, Moulton, Jeremie-​Brink, & Hansen, 2012).
You will frequently be working with clients from other cultures who do not under-
stand how people with power in the dominant groups view their behaviors. By using the
AWARE model, you can bridge cross-​cultural work:

Accept the other person’s behavior without judging it against your culture
Wonder what the behavior means in their culture
Ask what it means to the person, showing respectful interest
Research and read about the culture
Explain what the behavior means in your culture and give examples so the person
can learn new behaviors that will help the person function in your culture

Returning to the discussion of Joe, perhaps you could use the AWARE model to
explore how his behavior in the job interviews and visits to apartments to rent is inter-
preted in this culture. You can provide the opportunity for Joe to explore how his beha-
vior has meaning in his culture that does not come across in that way in this culture. In
working cross culturally with Joe, you have an opportunity to honor his culture and help
him strategize for success.

24 • Moving Beyond Assessment

HONORING DIFFERENT VALUE SYSTEMS
In our everyday life, we encounter people who have different beliefs and values from our
own, so it makes sense that this is true in our role of helping others as well. Our reactions
to these occurrences in our professional experiences must be guided by the social work
principle of starting where the client is. We have to remember to place the client’s world-
view front and center, not our own (Blow, Davis, & Sprenkle, 2012). Our value systems
come from our identity, which is influenced by culture, community, social group, reli-
gious teachings, family, and other sources. These values often guide our decisions and
behaviors, and when we act in opposition to them, it often causes feelings of shame or
guilt (Schmitz et al., 2001).
We all carry biases. Expecting that you will be bias free is unrealistic. What is expected
is that you will value the belief system of your client and not impose your own beliefs on the
client (Smith, Li, Dykema, Hamlet, & Shellman, 2013; Walker & Staton, 2000; D. Williams
& Levitt, 2008). For example, imagine you are working with a single mother grappling with
no financial resources. She tells you that, even though she lacks any form of financial sup-
port from the father of her children and is having trouble putting food on the table, she feels
strongly that she should not work so she can be at home with her children. You may hold a
bias that women should work to support their families and therefore judge the client for not
putting forth the goal of finding a job as part of her work with you. What you come to find is
that the client places great value on staying home to raise her children and being home for
them when they need her. This value is rooted in her childhood experiences as a latchkey
kid and feeling that her mother was never there when she needed her. If you attempt to
impose your own belief regarding work onto her, your bias will most likely create a rupture
in the working alliance (Safran, 2000), and you will be devaluing the (unpaid) work she is
doing in raising her children. Instead, you could honor her value system by cocreating a
goal with her to address family finances and means of financial support.
Clients will often make choices or set goals that go against your values and beliefs.
We have had many conversations with supervisees and students about these practice sit-
uations. We have had these feelings myself as well. The task is to separate out what “I”
would do from what “the client,” using their values and self-​determination, must do to
be true to their value system. Should your client leave his or her marriage or stay for the
children? Do your client’s religious beliefs influence what the client is and is not willing
to do to address family planning or fertility issues? Does your adult client continuing to
live at home derive from “failure to launch” or a practice that is culturally normal or even
economically prudent? When you work with the client’s values and beliefs, you will have
a clearer answer.

WORKING WITH SIMILARITIES

Sometimes, it is not the experience of working with those different from us that is most
challenging; working with people who share similar experiences, identities, cultures, and

Cultural and Identity Issues in Practice • 25

values presents its own difficulties. Some research explored the effectiveness of matching
clients and workers based on identity similarities. This research generally showed that
outcomes tended to be no different, or just marginally better, when there were similarities
than when differences existed (Bryan, Dersch, Sterling, & Aredondo, 2004; Coleman,
2006; Erdur, Rude, & Baron, 2003; Farsimadan & Draghi-​Lorenz, 2007; Hall, Guterman,
Lee, & Little, 2002; Murphy, Faulkner, & Behrens, 2004; Taber, Leibert, & Agaskar, 2010;
Zane et al., 2005). Working across similarities can create its own risks or problems.
First, we run the risk of assuming we “get” the client’s experiences when we really do
not. As mentioned, the client may not see you as similar to them. If you want to reassure
the client that you understand them and their situation without directly exploring it, you
will most likely have to say why it is you think you do.
Many of you may know what it is like to struggle financially, be a person of color, be
a descendent of slaves, come out as gay, hold religious beliefs that are not widely held,
experience neglect as a child, have a mental health diagnosis, or have many other lived
experiences. Yet, those experiences are personal to you. If you then perceive your personal
knowledge to be universal by assuming that you “know” what any of those experiences
feel like, you may choose not to explore what those experiences were like for the client.
When you assume you know, you shut down dialogue. When you act from the stance of
not knowing, you are fully aware that you do not know. Also, remember that even if you
think you have experienced the same form of oppression as your client, this is not a short-
cut to understanding how it felt for him or her.

TO SELF-​DISCLOSE OR NOT
SELF-​DISCLOSE—​THAT IS THE QUESTION
Our desire to connect our own experiences to our clients’ is understandable. It is also
understandable that clients would want to know about us as well. In many other situations
when we engage with people who have similar experiences, it is common to connect in
relation to those similarities. These experiences can involve something that is seemingly
benign, such as having visited the same geographic area, or they can be more personal,
such as sharing the same cultural heritage. However, as we discussed in Chapter 2 on
boundaries and self-​d isclosure, the relationship that we form with our clients is not a typ-
ical relationship, and our efforts to connect to them by sharing our stories can often shift
the focus away from the client and on to us. In addition, the client may see the experiences
as different from his or her own, begin to compare you to him-​or herself, or have a range
of other reactions; in the meantime, you may end up disclosing more information about
yourself than is appropriate.
For example, when I (E.D.) worked at a rape crisis center, clients frequently asked
how I could help them if I did not know what it was like to experience sexual violence.
They would often directly ask if I had similar experiences to theirs. When I was new to
the work, I was anxious about the many differences that existed regarding race, ethnicity,
socioeconomic status, gender, religion, sexual orientation, age, and others. But, here was an

26 • Moving Beyond Assessment

experience that crossed all groups. My clients wanted to know how I thought I could help
them if I did not know what it was like to be them? I decided to never directly answer that
question. If I answered no, then I ran the risk of losing credibility; if I answered yes, then
I ran the risk of invalidating their experience by creating an assumption that I knew what
their experience was like. In reality, that question was not about similarity or difference,
but about whether I knew how to help them. When I would ask, “What is it you really need
to know about me to work with me?” the answer was typically, “I need to know that you
understand what I am going through and can help me.” The answer to that question was
always yes.
We do not mean to imply that you can never share a lived experience with a client. If a
client is traveling to or from a particular area where we have been, we can share our expe-
riences of that place. If a client mentions his or her love of a type of food, then we can also
discuss our feelings about that food. While these may appear to be silly examples, they
are meant to illustrate that even as we are careful and intentional in this relationship, it
is still a relationship. Being a complete “blank screen” or neutral to the point of having a
nonpersonality is not helpful.
For example, in my (M.D.G.) work, I often use metaphors to help illustrate a point I am
trying to make. Sometimes, sharing a common interest can help you use metaphors more
effectively as it is a common language that you both “get.” At one point, I had a client who
participated in a similar hobby as I do. I found that sharing that I also participated in this
hobby was helpful as I was able to use the hobby as a metaphor for some of the points we
were discussing. I believe that the metaphors and “lessons learned” were more meaning-
ful and had more credibility because the client knew that I understood that world.
In thinking about what to share, we encourage you to be intentional, purposeful,
and deliberate about what you disclose regarding any similarities and differences that
you perceive between yourself and the client. Part of this reflective process is to consider
very carefully why you feel it would be helpful to the client. Whose needs are you serving?
Remember our motto of self-​d isclosure—​when in doubt, don’t!

FINAL THOUGHTS ON IDENTITY

AND DIFFERENCE
As you contemplate how you want to convey to your clients a desire to understand their
lived experiences, including how experiences of oppression, power, and marginalization
have had an impact on their lived experiences, remember a few key points:

• Be alert to social identity and norm/​other differences.

• Seek to learn more about that which you do not know.
• Always assume your world is different from your client’s.
• Realize you are not bias free.
• Know your own cultural lens and what you are likely to project on others.
• Identify and focus on the most salient cultural aspects at the moment.

Cultural and Identity Issues in Practice • 27

 • Gain knowledge of the dynamics of oppression, power, racism, discrimination, and
stereotyping.
• Be open to learning from your client.
• Become comfortable with discussing difference, oppression, and power openly and
honestly.

Also, be aware that the client–​practitioner relationship will be marked by a variety of com-
binations of differences and similarities. In some cases, as the worker you will feel that the
client has had more privileges and power than you, and this can make it difficult to own
your role. Much of the writing about working across differences with clients assumes that
the worker comes from privilege and the client from an oppressed or marginalized popu-
lation. This may not be the case, so keep in mind that the experience of difference will vary
based on the identities of client and practitioner.

CHAPTER 3 RESOURCE GUIDE

LINKS TO SELF-​A SSESSMENTS AND ONGOING
LEARNING TOOLS IN RELATION TO DIFFERENCE
Association of American Medical Colleges. (1995–​2 014). Tool for assessing cultural competence training.
Retrieved from https://​w ww.aamc.org/​i nitiatives/​tacct/​
Harvard University. (2011). Project Implicit ®. Retrieved from https://​i mplicit.harvard.edu/​i mplicit/​
Management Sciences for Health Organization and US Agency for International Development. (n.d.).
Quality and culture quiz. Retrieved from http://​erc.msh.org/​mainpage.cfm?file=3.0.htm&module=
provider&language=English
National Center for Cultural Competence. (n.d.). Self-​a ssessments. Retrieved from http://​nccc.georgetown.
edu/​resources/​assessments.html

28 • Moving Beyond Assessment

 CHAPTER 4

YOUR ROLE AND RELATIONSHIP

WITH YOUR CLIENTS

I n our opinion, one of the best parts of our profession is the number of
roles social workers can hold as professionals. Social workers can be found virtually every-
where people are in need of support. They are in hospitals; schools; community mental
health clinics; psychotherapy practices; jails; local, state, and federal government depart-
ments; community organizing agencies; spiritual communities; homeless shelters; and
other places too numerous to count. Within each of these settings, social workers hold a
number of different roles that influence their responsibilities to the agency and the clients.
To describe each and every possible role a social worker can take in a professional career
would be impossible. Therefore, this chapter was designed to have you think through
some questions to help you better understand your role in your setting so you can be as
effective as possible.
In addition, the role you have with your clients will influence the type of helping rela-
tionship that you may form with them. The social worker–​client relationship is an import-
ant aspect of the helping partnership that you will create with your clients. This chapter
also explores some of the critical elements that encompass an effective relationship as we
keep in mind the role you and your agency play in lives of your clients.

SOCIAL WORK ROLES

As just stated, it would be impossible to adequately describe every possible social work
position and its corresponding role and responsibilities within an organization. Yet, there
are some broad categories often used to describe social workers’ roles within agency set-
tings. Hepworth, Rooney, Dewberry-​Rooney, and Strom-​Gottfried (2013) described
broad categories of direct practice roles and the specific functions of those individuals
within them (see Table 4.1).
It is important to note that some of these roles are perceived as more in line with
social workers who work to create social change on a macro level. However, many social
TABLE 4.1: Social Work Roles

Role General Description Possible Position

Direct provision Meet face to face with •  Individual caseworker or counselor
of services clients to provide •  Couples and family therapist
services •  Group work services provider
•  Educator/​disseminator of information
System linkage Link clients to people •  Broker—​an intermediary who assists in
roles and other resources connecting people with resources
•  Case manager/​coordinator—​assesses the
needs of a client and arranges and coordinates
the delivery of essential goods and services
by other resources
•  Mediator/​arbitrator—​works to eliminate
obstacles to service delivery
•  Client advocate—​works with or on behalf of
clients to obtain services and resources that
would not otherwise be provided
System Evaluate structures, •  Organizational analyst—​identifies factors in
maintenance policies, and agency structure, policy, and procedures that
and functional have a negative impact on service delivery.
enhancement relationships within •  Facilitator/​expediter—​plans and implements
agencies that impair ways of enhancing service delivery
effectiveness in •  Team member—​contributes knowledge
service delivery to an interdisciplinary team
•  Consultant/​consultee—​provides expertise
on a particular topic as a consultant; assumes
a consultee role when expert knowledge
from another is needed
•  Supervisor—​assists staff in linking
assessment with intervention plans and
evaluation
Researcher/​ Select interventions •  Researcher—​evaluates effectiveness of an
research that can be evaluated; intervention
consumer evaluate the •  Research consumer—​uses research to
effectiveness of their select appropriate interventions
interventions; and
systematically monitor
the progress of any
intervention
System Improve or expand •  Program developer—​develops services in
development agency services response to emerging needs of clients
based on •  Planner—​works formally and informally with
assessments influential people to plan programs
and research that respond to unmet and emerging needs
•  Policy and procedure developer—​formulates
and modifies policies within agencies that
primarily serve clients
•  Advocate—​joins client groups, other social
workers, and professionals in advocating
for legislation and social policies aimed at
providing needed resources and enhancing
social justice

Note: Adapted from Direct Social Work Practice: Theory and Skills (9th ed.), D. H. Hepworth, R. H Rooney, G.
Dewberry-​Rooney, and K. Strom-​Gottfried, 2013, Brooks-​Cole, Belmont, CA, pp. 30–​3 4.
workers, regardless of their identified role, may work in multiple systems and hold mul-
tiple roles. It is for this reason that some authors have referred to the functions of social
workers rather than to a designated role, as many of these functions cut across different
roles within any one agency (Gambrill, 2013). According to Gambrill, the major func-
tions of social work include “1) relief from psychological distress and material need;
2) social control (e.g. maintaining social order and regulating the labor market); and
3) social reform (altering the conditions related to the psychological distress and mate-
rial need)” (p. 8). What Gambrill meant by social control is “encouraging adherence
to social norms and minimizing, eliminating, or normalizing deviant behavior” (p. 8).
She provided many examples of formal functions of social controls, such as laws, pub-
lic health regulations, and institutions that are concerned with social control, such as
educational, criminal justice, and social welfare agencies. Each of these functions can
be carried out within multiple roles that social workers hold within their own agencies
or organizations and may at times appear to be in conflict with each other. Therefore,
while we have presented different categories of roles here, it is important to remember
that social workers may be responsible for many different functions even within one
described role.

WHY IT MATTERS
Given this range of possibilities, you may be asking yourself why it matters so much to
define your role when it may change moment to moment. There are actually multiple rea-
sons why you need clarity regarding your role.
The first reason is that being clear about your role protects you personally and profession-
ally. This clarity increases the likelihood that you will be successful in your position as you
gain a solid set of skills and knowledge that are specific to your position. Being clear also
increases the likelihood that you will not cross boundaries with clients by making prom-
ises you cannot keep or set up unrealistic expectations that you and your agency cannot
meet. Many of these potential situations may seem obvious (e.g., providing individual
therapy where you ask personal questions to a client versus when your role is limited to
gathering demographic information for a form), yet many of them are less obvious. For
example, less experienced social workers may feel that given their therapeutic role with a
client, it makes sense to be the one to investigate an accusation of sexual abuse rather than
referring the client to someone in a forensic role. However, an investigator has different
responsibilities than a therapist. If you are seen as unable to stay within your role, you
could set yourself up for ethical or legal violations that jeopardize your ability to continue
to practice.
The second reason to be clear about your role is that it is protective to the clients. Many
clients have lives that are chaotic and unclear. It is important to be clear and consistent
with them regarding what you can and cannot do for them. This clarity provides a sense
of predictability that is important for safety and security in a relationship. It is helpful to
be clear up front so that the boundaries of your role are clear, ensuring that their expecta-
tions of you are in line with your role.

Your Role and Relationship With Your Clients • 31

 The final reason for you to be clear about your role is for the benefit of your colleagues
and organization. If you think about any agency as a beehive, everyone has a job to do
and if everyone does his or her job, the beehive works well. When different people begin
to duplicate the work of others, not only is this style of working inefficient, but also it can
create tension and frustration among those who work together. An attempt to be “helpful”
by taking on the role of another colleague could be interpreted as a lack of trust in that
person to do his or her job or that you believe you can do it better. These interpretations
can lead to multiple conflicts and challenges within the workplace. As mentioned, when
multiple individuals carry the same duties, there can be a great deal of inefficiency that
occurs. Therefore, it is important for the agency and your collegial relationships to be clear
about what your specific contributions are to the organization.
We would like to put forward a caveat before moving on to the next section. We have
both worked in organizations where employees became the “jack of all trades” out of
necessity. There are many agencies where employees do a little bit of everything in order
to keep the agency afloat. We are not saying that social workers should be rigid about any
one role that they assume. It may be that the expectation is that each employee will take
on multiple roles within one context. This phenomenon is actually common. Therefore,
it is important whether you wear one hat or multiple hats in one setting to gain as much
clarity as possible in identifying what your specific roles are within that setting.

HOW TO DEFINE YOUR ROLE

WITHIN THE AGENCY
One of the best sources to start understanding your role within the agency is your super-
visor. We cannot emphasize enough the importance of having clear conversations with
your supervisor to help you clarify your responsibilities. For example, if one of your major
responsibilities is program development (i.e., developing a new aftercare program at a
school), then little of your time may be spent working with the children in the school in a
therapeutic manner. The majority of the time with the students and their families may be
focused on understanding what the needs and wishes are for this group so that you can
design an effective and responsive program. If in the same setting, however, your respon-
sibilities are to counsel the children, then you might spend much of your day in sessions
with them either individually or in a group. Both of these roles are well within the purview
of social work but require different knowledge bases and skill sets. Therefore, it will be
important for you to gain clarity regarding your role so that you can utilize or develop the
appropriate skills and knowledge needed for that role. Another reason to focus on your
own role is to ensure the work is completed. If you spend much of your time outside your
role doing other tasks, then the work that is your responsibility is not being done.
To be most effective in your position, we encourage you to ask your supervisor ques-
tions that will help to clarify these aspects of your role. The list that follows provides
guiding questions that might help you in this conversation. These questions are meant as
options and may feel slightly redundant because they are all designed to ultimately gather

32 • Moving Beyond Assessment

the same information. We provide here a range of options so that you can identify which
ones feel more appropriate or more “your style” than others.

• What would a typical day look like for me?

• How would you describe my primary responsibilities?
• On what criteria will I be evaluated on any performance reviews?
• What specifically are you hoping I will accomplish by “X date”?
• What are the limits of my role? Is there anything I should not focus on in my
position?
• What skills do you anticipate I will need the most to be successful in my position?
• What knowledge do you anticipate I will need the most to be successful in my
position?
• Are there particular individuals within the agency who it might be useful for me to
shadow or observe to better understand my role and responsibilities?
• How will I know if I am carrying out my role well?
• Are there particular outcomes of my work that you would like to see?
• Who will be giving me feedback about my roles and responsibilities?

THE SOCIAL WORKER–​CLIENT

RELATIONSHIP
The relationship that social workers form with their clients is a critical component in the
change process (Hubble, Duncan, Miller, & Wampold, 2010; Teyber & McClure, 2011;
Walsh, 2013; Wampold, 2010). Numerous studies over the last two decades have evalu-
ated the impact of the practitioner–​client relationship on outcomes with clients (Lambert
& Barley, 2002; Walsh, 2013; Wampold, 2010; Weinberger & Rasco, 2007). The majority
of these studies have concluded that two primary elements account for positive outcomes
in direct practice more than anything else: “(a) the therapeutic alliance and (b) the prac-
titioner’s ongoing attention to the client’s perspective about the intervention” (Miller,
Duncan, & Hubble, as cited by Walsh, 2013, p. 7). Given these findings, it is critical for
social workers to learn to develop relationships that will be effective in contributing to the
change process.

THE DODO VERDICT

The importance of the alliance in relation to skills, resources, or tools that practitioners
provide to their clients using specific models of intervention has long been debated
(Weinberger & Rasco, 2007). The debate about the importance of particular techniques
or models and their role in outcomes is often referred to as the “dodo verdict” (Duncan,
2010; Weinberger & Rasco, 2007). This phrase owes its origins to the story of Alice in
Wonderland by Lewis Carroll (1865/​1962), which presents a famous race among different

Your Role and Relationship With Your Clients • 33

animals. The animals scatter around the field, and at the end of the race the dodo bird asks,
“Who has won?” Dodo Bird quickly responds, “Everybody has won, and all must have
prizes.” This story has been used as a metaphor in outcome research of different interven-
tion models to explain the controversy between those who believe that there are specific
and discrete approaches or models of intervention to address certain issues, otherwise
known as empirically supported interventions (see Chapter 10), versus those who believe
in what is known as the common factors (CFs) (Duncan, 2010).
This debate among practitioners from multiple disciplines stems from the CF research
that indicated that the outcomes for different models of intervention are similar; in other
words, no one model of intervention is superior to others (Duncan, 2010). To help under-
stand this finding, researchers began decades ago to look across all of the different models
and concluded that there must be “pantheoretical factors in operation that overshadow
any perceived or presumed differences among approaches” (Duncan, 2010, p. 9). The idea
with these pantheoretical or CFs is that different interventions work because of what they
have in common, rather than what makes them different from each other (Weinberger &
Rasco, 2007). There is now a large body of research to support these CFs and their import-
ant role in influencing the outcomes in direct practice.

COMMON FACTORS
The research on the CFs in client outcomes boils down to four primary domains. Past
research on the CFs has listed the four domains as client characteristics, therapist quali-
ties, changes processes, and techniques (Bogo, 2006; Hubble et al., 2010). However, more
current research has shifted these domains a bit, placing more emphasis on the alliance
that is formed with between the practitioner and the client (Hubble et al., 2010). These
domains, while independent of each other, are also interdependent, meaning that each
influences the other to some degree (Hubble et al., 2010).
Extratherapeutic or client factors: These factors are the clients’ internal and external
resources. These factors include the “clients’ readiness for change, strengths, resources,
level of functioning before treatment, existing social support network, socioeconomic
status, personal motivations, and life events” (Hubble et al., 2010, p. 35). Other charac-
teristics within this factor are the clients’ expectations, help-​seeking activity, and distress
level (Bogo, 2006).
Models and techniques: The use of models and techniques plays a critical role in improv-
ing outcomes, but not necessarily because one approach is better than another (Hubble
et al., 2010; Wampold, 2010). They are important because they activate the feelings of
hope and expectancy and increase the placebo effect (Hubble et al., 2010). The placebo
effect is when clients demonstrate improvement simply because of their expectations that
whatever they are doing will improve their condition or situation (Kirsch, 1985). In addi-
tion, models and techniques engage the client in “healthy and helpful actions,” and they
“offer the client an appropriate explanation for his or her difficulties and set forth strate-
gies for problem resolution” (Hubble et al., 2010, p. 36). In a sense, models and techniques
provide structure to the work. In fact, research shows that when there is a lack of road
map or theory to explain and organize the course of the plan for change, the outcomes

34 • Moving Beyond Assessment

are worse (Hubble et al., 2010; Wampold, 2010). It is essential that the practitioner has a
plan reflecting a rationale for what is being done, and that the plan makes sense and has
meaning to the client (Wampold, 2010).
Therapist factors: “Available evidence documents that the [practitioner] is the most
robust predictor of outcome of any factor ever studied” (Hubble et al., 2010, p. 38).
Although the research strongly indicated that the practitioner heavily influences the
outcome, what specifically the practitioner does is less clear. In other words, the specific
actions taken or characteristics shown by the practitioner that influence and improve
outcomes have not yet been identified. However, what appears to play a central role is
their ability to form a strong alliance with their clients (Hubble et al., 2010; Wampold,
2010). What matters is the practitioners’ ability to demonstrate “caring aspects of empa-
thy, warmth, acceptance, and validation that create[s]‌safety” (Bogo, 2006, p. 96) and
ultimately how they deliver a particular treatment rather than the specific treatment that
they deliver (Wampold, 2010).
Therapeutic relationship/​alliance: The relationship or alliance is “a partnership between
the client and therapist to achieve the client’s goals” and is “one of the best indicators of
outcome” (Hubble et al., 2010, p. 37). Research continues to show that there is a causal
relationship between the quality of the relationship and the outcome of the intervention
with clients, meaning that strong alliances lead to better outcomes (Weinberger & Rasco,
2007). What is important to remember about the alliance is that it is the practitioner’s
ability to form a collaborative partnership with the client that influences the outcome
(Hubble et al., 2010).

SO WHAT IS THIS THING CALLED

THE WORKING ALLIANCE?
As discussed, the alliance is the factor most written about in outcome research with
regard to social work and other disciplines’ interventions with clients (Weinberger &
Rasco, 2007). Essentially, the alliance is the connection that you have built with the cli-
ent. Although it may seem like it is a nebulous concept, there are valid instruments that
can measure this construct and in turn the strength of this relationship (see resource
guide for listing of sources). While there are many different variables that contribute to
the alliance, there are three main characteristics that define this relationship (Lambert &
Barley, 2002).
The first characteristic is tasks. These are the behaviors and processes within the inter-
vention itself that make up the actual work that occurs between the worker and the client
(Lambert & Barley, 2002). It is important that both the client and the worker see these tasks
as important and relevant to the client’s life. These tasks might include deciding how often
the meetings between the social worker and the client might take place or they might involve
what types of activities occur in addition to deciding each person’s roles and responsibilities
in the work together (Bogo, 2006). For example, if a client living in a homeless shelter comes
to a social worker in the hopes of finding safe housing, it will be important for the worker and
the client to agree on who will do which tasks to reach this goal. In addition, it is important

Your Role and Relationship With Your Clients • 35

for the social worker to clarify what he or she is able to do within his or her role, as well as
what the social worker is unable to do within that role to ensure that the client is clear on the
limits of the social worker’s role in helping to secure safe housing.
The second characteristic relates to goals. Both the client and the practitioner must
endorse and value the goals and purpose of the work they are doing together (Lambert
& Barley, 2002). Here, it is important to remember the social work principle of “starting
where the client is.” This principle means that social workers give priority to the client’s
stated goals, their views of the issues with which they are struggling, and their capacities
to manage those issues. (See Chapter 13 on creating goals and planning for treatment
with clients.) While goals may be established at the beginning, it is important to remem-
ber that the goals may also change during the time social workers work with clients.
Regardless of the content of the goals, it is essential for the alliance that the worker and
the client agree on the direction of the work together. For example, using the case men-
tioned, if the worker believes that the client should not look for housing until he or she has
learned anger management skills and begins to form a plan to address those skills rather
than housing, the alliance will suffer. The process of cocreating the goals helps cement the
bond of the working alliance.
Finally, the alliance also must include a bond between the practitioner and the cli-
ent where there is “mutual trust, confidence, and acceptance” (Lambert & Barley, 2002,
p. 25). This bond is formed when the worker is able to demonstrate attunement and under-
standing of a client’s thoughts and feelings, as well as be able to hold a nonjudgmental
stance (Bogo, 2006). In the example of the client who is seeking housing, it is possible that
the client could become frustrated with the process and feel that the worker was not doing
enough for him or her. If a bond existed between the worker and the client, then the client
could feel comfortable expressing frustrations because the client knows that instead of
rejection, the worker will listen to her concerns and feelings and work with the client to
redefine their tasks together. Without such a bond, the client might become hopeless and
give up on the process.

TAKE-​HOME MESSAGE ON THE RELATIONSHIP

What we hope is abundantly clear from this discussion about the relationship is that
your relationship or the working alliance that you form with the client matters greatly.
Regardless of your setting and your role within the setting, your ability to form a strong
working alliance with your clients is a significant factor in helping them to reach their
goals. Therefore, we encourage all readers to focus on building relationship skills through
coursework, supervision, modeling, role playing, and practicing with clients. To summa-
rize some of the research we discussed, beginning practitioners should focus on learning to

• Demonstrate empathy, genuineness, authenticity, and a nonjudgmental stance

• Create mutually agreed-​on goals that start where the client is
• Clearly articulate the intervention approach they will take with clients, including
the tasks, roles, and responsibilities of each person involved in helping to achieve
the clients’ goals

36 • Moving Beyond Assessment

 • Provide a rationale for their approach that links the explanation to the suggested
plan for intervention
• Provide a space for clients where they feel accepted and validated
• Use reflective listening skills effectively
• Attend to client factors, such as their motivation, and modify their approach
accordingly

CONCLUSION
Due to the varying roles social workers can have within different organizations, it is crit-
ical for social workers to understand their specific roles and related responsibilities. The
best method to define these roles and responsibilities is through conversations with the
social worker’s supervisor. Many issues can be avoided or minimized when social workers
are clear regarding the specific expectations held for them within their agencies.
Regardless of the role that social workers hold with clients, the most critical factor in
helping to improve outcomes for their clients is to learn how to form strong working alli-
ances. To strengthen these alliances, social workers should pay attention to the internal
and external resources of their clients, be able to provide the rationale for the intervention
approaches they are suggesting might be helpful, use relationship skills to create a bond
with their clients, create mutually agreed-​on goals that start where their clients are, and
clearly articulate the tasks, roles, and responsibilities that each individual will have in the
work together. These relationships exist regardless of whether you will work with your
clients for an hour in an emergency room or in a group home setting where there may be
hours of interactions over several months. One of the aspects of our work with clients that
makes this work so rewarding is the unique relationship that you have the privilege of
forming with your clients.

CHAPTER 4 RESOURCE GUIDE

We have provided below a list of two of the most commonly used instruments designed to
measure the relationship between the client and the social worker in social work practice.
There are others beyond this list, but we have included the two that we feel are most well
known and that are available for free.

1. The Working Alliance Inventory (WAI © A. O. Horvath 1981, 1984, 1992)

a. Available for free from http://​wai.profhorvath.com/​
b. Measures the quality of the relationship between the practitioner and the
client.
c. Both the client and the practitioner complete the forms.
d. It has undergone numerous evaluations and is considered a useful instru-
ment to measure this aspect of the work.

Your Role and Relationship With Your Clients • 37

 2. Session Rating Scale (SRS © 2002, Scott D. Miller, Barry L. Duncan, & Lynn
Johnson)
a. Available for free from https://​heartandsoulofchange.com/​
b. This instrument is designed to evaluate the client’s views of how well the
practitioner is addressing his or her goals, as well as the fit of the practi-
tioner’s style to his or her needs.
c. It is designed to be used at the end of the session and allows for “real-​t ime”
evaluation of the fit between the client and the practitioner.
d. It is completed by the client.
e. The SRS has been used internationally and when used has demonstrated
that client’s report significantly better outcomes.

38 • Moving Beyond Assessment

 PA R T I

BEGINNINGS
 CHAPTER 5

THE FIRST SESSION

S tarting new relationships of any kind can be a little unnerving. This is

certainly true of professional relationships that have a lot riding on our ability to connect
with clients and engage them in the process of setting goals and achieving the change they
desire. Both you and the client may find a first meeting a little awkward, as it is a different
sort of first meeting than you might typically have in another social or professional set-
ting. In addition, some people are more comfortable with initial interactions than others
may be. However, we can assure you that you will get better at navigating first sessions
over time. In this chapter, we offer a set of guidelines to help students and new practi-
tioners address some of the common concerns that may arise in these initial meetings, but
understand that there are agency and organizational guidelines and parameters that may
influence different aspects of these encounters. We also provide some legal and practice
guidelines regarding how to address these concerns.

PREPARING FOR THE INITIAL ENCOUNTER

Often before the first meeting, you or someone else from your agency may have interac-
tions with the client, such as phone discussions or e-​mail exchanges to discuss schedul-
ing. Other clients may just walk in or have been placed at your agency, such as a hospital
or school setting. It is important to remember that these first encounters with either
you or your agency can set the tone for how the clients might perceive you and your
ability to help them. We strongly recommend that you understand early on in your field
placements or your jobs how clients come to the agency. What is the process for clients
to gain access to your services? How welcoming is the process? How difficult is the
process? It can be helpful for you to walk through the experience as if you were a client
to see what it feels like to engage with the agency. Here is where you can put on your
macro/​organizational hat and view the process through a systems lens to see if there
are ways to improve the process to ensure that clients feel welcomed and attended to,
starting with their initial contact with the agency or the individual with whom they
will work.
 Once the first session is scheduled, you will also have to navigate the initial greeting
before settling into the space you will be using for the meeting. These exchanges should
be given a great deal of careful thought; they can set a tone for how the rest of the meeting
will feel. For example, if you are greeting the client in a waiting room, do you call out his
name? Do you refer to him as Mr. Smith or use his first name? If coming into a client’s
hospital room or home, do you walk right in or ask permission to enter and inquire about
where you should sit? When greeting a client for the first time, do you initiate a hand-
shake? These questions contribute to feelings of nervousness.
It is helpful to discuss these questions with your supervisor to help navigate these
microinteractions. If you do not have this opportunity, it is best to abide by confidenti-
ality and not call out a client’s name in a waiting room. Instead, you could ask the group
of clients waiting which person has an appointment with you. Also, it is a good operating
principle not to initiate a handshake or other touch with a new client. There may be cul-
tural norms that prohibit this kind of touch, or you may make the client feel pressure to
shake hands when the client would not otherwise. Take the lead from the client and let
the client set the pace.
You will also need to introduce yourself to the client. While this may seem like an
obvious statement, it is actually a complicated interaction and one to explore with your
supervisor. In some settings, such as in a school or some shelters, the expectation will
be that you will use your last name and be called Ms. Smith or Mr. Jones, for example.
In other settings, you and the other staff may be called by your first name only. Again, it
is important that you talk with your supervisor regarding how other staff members are
called. It is much more difficult to backtrack than to start off on the right foot.
Beyond your name and role at the organization, there will be questions the client may
have about who you are and what qualifications you have; in other words, the client wants
to know, How can you help me? Here is the first test of your honesty as well as your confi-
dence. Be sure to directly address your role as a student intern or new professional. There
is a fine line between being honest about your lack of experience and instilling confidence
in your abilities. You may want to consider rehearsing a statement about yourself in super-
vision or with a peer. Spend time role-​playing a first session to generate ideas of authentic
statements. Perhaps you could say something like, “My name is Eileen, and I am a student
intern here at XYZ Services. I will be meeting with you once a week to work on your goals,
and I will be meeting weekly with my supervisor, who will help guide our work together.
Do you have any questions for me about my role here or this process?” Handling these
questions openly and honestly will help develop trust. If the client has any reservations
about working with a student or new practitioner, be sure to let the client know that you
understand their concerns and reassure them that you have the necessary education and
skills to help them. When a practitioner has close supervision like you will, clients actu-
ally haves more agency resources focused on them and their goals, and this can be seen as
a benefit rather than a deficit.
To calm your jitters and focus on the meeting with this new client, take a few
moments to center yourself. Breathe, clear your head, and get ready to listen. You
have learned about listening skills in your coursework, so have confidence in what
you already know and the skills you are beginning to hone. Be curious and without

42 • Moving Beyond Assessment

judgment about this particular client. The client may be similar to people you know or
have worked with in the past or even yourself, but there is much you do not know about
this client. The client is the expert on his or her life and situation. You have a set of skills
and techniques that you can use to help the client as you work together toward setting
and achieving the client’s goals. Know you are capable of “being with” clients and that
you cannot solve a client’s problems today. It is possible that much of what he or she is
coming to the agency to address has been an issue for years and cannot be “fixed” or
resolved in one or two meetings. Keep in mind that there are three main tasks for the
first session:

1. Create a safe environment for you and the client.

2. Establish a trusting relationship.
3. Set the frame of the work and attend to intake forms, treatment plans, and other
paperwork.

CREATING A SAFE ENVIRONMENT

Your ability to create a safe environment in which you and your client will meet is
influenced by your role, the organizational setting, and many other variables. In some
settings, you will be meeting with clients in the same space every time. In this case,
ensure that you have soft lighting, tissues, visible clocks, and comfortable seating that
is neither too close nor too far apart. In other practice arenas, you will be working in
a host setting, where mental health services are not the main focus and are seen as
adjunctive to the mission, such as in hospitals and schools. In these settings, meeting
space may be hard to come by and less than ideal for your purposes, as it may be dif-
ficult to create quiet spaces where you will have privacy. In these situations, it can be
helpful to let those around you know why your work requires privacy and request their
help. You may want to consider keeping a “do not disturb” sign, tissues, a clock, and
other items with you for use in any space.
Finally, when your work requires you to enter hospital rooms or go on home visits, you
never know what the environment will be like. In these situations, talking with the client
about why turning off the television or meeting in private will be helpful to the work you are
doing together and can establish understanding that you are both responsible for this work.
Regardless of your setting, it is important for you to keep in mind both your and your client’s
physical safety. We spend more time addressing this issue in Chapters 8 and 9. However, in
the context of your first meeting, it is important for you to keep in mind a few issues:

• Notice where you and your client are located in relation to exits.
• If your client is known to have a history of violent behavior, make sure that another
staff member is aware of when and where you are meeting.
• If you are conducting home visits or working in the community, request specific
safety training before you begin making visits.

The First Session • 43

ESTABLISHING A TRUSTING RELATIONSHIP
Trust is an essential component of helping relationships. To share details of their lives,
clients will need to feel that they can trust you. You may be the first person with whom
they have ever shared their story, and there may be parts of this story about which they
feel some collection of difficult emotions, such as shame or guilt. We mentioned that it
is important for you to learn to be curious, nonreactive, and nonjudgmental. As clients
begin to share their stories in the initial meeting, it is essential that you practice these
skills to establish trust from the beginning of the relationship.
Let us pause for a moment to address this concept of being nonjudgmental. It is not
really possible to be without judgments. We are all human, and it is natural to have initial
impressions or judgments (which can range from very positive to very negative) about
your clients, just as they will have their initial reactions to you. For example, clients might
remind you of someone in your past; you might have initial judgments based on perceived
social identity differences or from reading about the clients in their case file. It is import-
ant to notice your reactions and discuss them with your supervisor to prevent them from
being felt by your clients or interfering with the professional relationship you are building
with them.
Confidentiality is another crucial component of the professional relationship. In your
role as a professional social worker, you will not be sharing what clients tell you with
friends and family members. While you have heard this many times before, it is important
to clarify what confidentiality means in the context of this relationship with your clients
as this knowledge can help them to feel more comfortable being open and honest with
you. However, even with this knowledge, you cannot assume that a client will feel safe
enough to trust you right away.
Trust is typically earned over time, and with some clients you will really have to earn
it. Some clients may say or do things to test whether you are trustworthy. For many cli-
ents, given their own personal histories, their reluctance to trust you and to first deter-
mine if you are trustworthy are completely understandable. Take a moment and think
back to a time when someone broke your trust. This type of experience can be painful and
can make you wary of trusting others in the future. The more extreme trust violations are,
the more self-​protective and mistrustful we can become. It is important not to judge cli-
ents who do not trust you right away. Know that this can be a healthy process of evaluating
another’s trustworthiness; in other words, this is a strength that can be reflected back to
the client. You can normalize the process of building trust in relationships and ask clients
what they see as barriers to trust or indicators that they can safely open up.
As part of building a trusting relationship, it is important to be honest with clients
about confidentiality and its limits. It is normal to want to reassure clients that “every-
thing you say will be kept confidential.” However, this is not the case in most practice
settings. You share what clients say with supervisors, administrators often review case
notes, and there are situations for which you are required by law to break confidentiality.
Confidentiality often extends to others outside your practice setting, so let clients know
that you receive supervision where you may discuss your work with them so you can
obtain the best guidance to help them. Be clear about the situations for which you need to

44 • Moving Beyond Assessment

break confidentiality, such as when they are a danger to themselves or someone else. As a
mental health professional, you are a mandated reporter, which means that there are laws
that require you to report information about physical and sexual abuse of a minor or vul-
nerable adult. These laws vary by state, so familiarize yourself with the laws in the state(s)
or jurisdictions where you are working. It is common for neighboring states to have dif-
ferent laws, and it is your professional responsibility to understand these differences. This
topic is covered in more detail in Chapters 8 and 9.

SETTING THE FRAME AND ATTENDING

TO PAPERWORK
In addition to introducing yourself to the client and working to establish a sense of safety
and trustworthiness, you have some business to which you often must attend. In many
settings, you will be required to complete an initial intake, fill out insurance forms, review
informed consent documents, and attend to other paperwork. It can be challenging to bal-
ance the relational part of this meeting with the administrative requirements; let the client
know at the beginning of the meeting what you have to accomplish. If you start with “tell
me what brings you in today . . . ” and spend 30 minutes listening to the client’s life story,
you may be rushed at the end of your time together to complete all the paperwork and
not do a good enough job of validating and responding to what you just heard. Consider
beginning this first session with, “We have a couple of things to do in our meeting today;
I have some paperwork we need to fill out and forms for you to sign, but I also would like
for us to spend a little time getting to know each other and for you to tell me what brings
you in today. Where would you like to start?” This way you set a tone of honesty, openness,
and partnership. By laying out all the tasks that you have to accomplish together, you are
transparent, and by asking where the client wants to start, you are putting the client in the
driver’s seat. Most helping relationships feel unbalanced, with you in the powerful role of
helper and the client in the help-​seeking role. Efforts like this one can help create more
balance in the relationship and set the frame to be one of collaboration.
One of the key pieces of paperwork is asking the client to give his or her informed con-
sent to treatment. While this is often seen as a formality in some settings, it is a key part of
establishing trust and setting the frame of the relationship. It is your opportunity to spell
out the benefits, as well as any risks, associated with receiving services. Ideally, you will
point out the informed consent document to clients and ask that they read it carefully
and take time to answer any questions they may have about the services they will receive.
This step is vital to ensure that your clients understand what they are agreeing to in this
process.
Setting the frame for your work together also requires you and the client to review
the ground rules for the meetings. How long will each meeting last? Will you meet once a
week? Where will the meetings take place? Will the location be the same for each meeting,
or will it vary? It is also important to address the boundaries of the relationship, like what
limits there are on contact outside of meetings. These include how you will communicate

The First Session • 45

with each other, such as the use of phone or e-​mail. The use of technology in providing
services is addressed in more detail in Chapter 17. We encourage you to be careful about
establishing rules consistent with your setting; you do not want to set up an expectation
with clients that you then have to change. In addition, if there is a possibility that you
might see a client outside the agency, you will want to think about how will you handle
such encounters.
For example, I (M.D.G.) worked with an adolescent client who lived near my home
and my office and in fact did swim practice at my same gym. We discussed ahead of time
what she would like to do if she saw me in the community. She decided that she would like
to be the one to acknowledge me first as there may have been a time when she was with
someone with whom she did not want to share who I was. It was good we discussed this
plan ahead of time as we saw each other several times outside the office. It is important not
to assume that the client will be familiar with the culture and norms of mental health ser-
vices in general or your practice setting in particular and to socialize them to this unique
relationship.
If the client has received services before, it is helpful to explore what this experience
was like and how he or she felt about it. This discussion can be a good opportunity to
process what the client needs from you and to address his or her expectations of your
organization or program. It is also important during this discussion to be clear about and
obtain a mutual agreement on the frame of the work and clarify the policies concerning
missed appointments and any scheduling constraints. This initial meeting is also a good
time to explore what the client considers a good outcome from your work together. How
will the client know when personal goals have been achieved? What will ending the work
together look like? It may feel too soon to discuss termination, but this is an integral part
of setting the frame, as you and the client are embarking on a professional helping rela-
tionship that has a beginning, middle, and end. It is helpful to keep the end in mind as
you proceed and plan for it to be a positive experience for you and the client. Further in
this book, we discuss establishing clear goals and planning for endings, as well as how to
evaluate whether the work you and your client have done has been effective in reaching
the client’s goals.
Finally, it is essential to leave enough time to explore any questions the client may
have. If the client is particularly nervous, he or she may not have heard all the information
you have shared. It is important to keep in mind any cultural norms that may influence the
client’s willingness to ask you questions. In some cultures, you may be seen as “the doc-
tor” or someone with power who should not be questioned. In addition, the differences
or similarities between you and your client in terms of gender or age may influence the
client’s comfort level in asking you questions. Other clients may look for physical signs
on you or in your meeting place to see if you are a “safe” person so they can speak freely.
For example, they may look for a religious symbol, such as a cross or star of David on a
necklace, or look for a pink triangle or rainbow in your office before feeling safe to ask
additional questions. For other clients, these same symbols may deter someone from ask-
ing questions. As discussed in Chapter 2, “What to Know Before You Start,” there are no
hard-​and-​fast rules for what to wear or what to have in your space. It is just important to
be cognizant of the symbols with which we surround ourselves and the impact that these
can have on our clients.

46 • Moving Beyond Assessment

 Finally, allow time to summarize what you have heard and discuss the plans moving
forward. For some social workers, the initial meeting may be the only time that they will
ever see a client. Regardless of how long you will be in the life of this client, it is helpful
to summarize the initial session and review with them the time for their next meeting
if one is to occur. Be sure to clearly state with whom the meeting will take place, where
they should go for it, and who they should contact (it may be you but could be someone
else) if the client has any questions about the appointment.

DIFFERENCES AMONG CLIENTS

It is important to make note of how different clients influence the initial encounters. For
example, a client who is voluntary, or is seeking services of his or her own desire, will,
and volition may engage with the practitioner differently from someone who is mandated
to receive services. Mandated clients are typically those who would not otherwise seek
services but are being told they must receive services. In some cases, clients are mandated
by the courts or their employer or are receiving pressure from a friend, family member,
or partner to obtain help (or else). Be sure to make note regarding whether the client has
chosen to be there or not as you begin the work.
If someone is reluctant or resentful, they may not be so forthcoming with information
and may be slow to engage with you and the work. It is also important not to make the
assumption that a mandated client will be difficult to work with as some may actually
embrace the experience. We encourage you to empathize with the situation they are fac-
ing and find a mutual goal or hope for the work. When you convey to the client that you
understand why they resist change, you actually join together in the process instead of
setting up a struggle for power. For example, you could acknowledge their frustration and
make a statement such as, “Having to come in to XYZ Services each week for services you
don’t feel you need must be frustrating and feel like a waste of your time.” After you have
acknowledged their frustration, you can then follow up with a question such as, “Since we
need to meet each week for 6 weeks, is there some way to make this time feel valuable to
you and not just check off a box for the court system?” This type of exchange may help the
client feel more engaged.
In the same vein, it is also important not to always assume that voluntary clients will
be easy to work with. For example, although your client “Jane” knows she needs to make
changes or engage services to help her establish and maintain sobriety, this knowledge
does not mean she will be without ambivalence or resistance to the process or outcome.
Often, there are secondary gains to the status quo of people’s lives. When Jane makes
changes in herself, it will have ripple effects to the rest of her life. So, while Jane may have
voluntarily committed to sobriety and wants to stop drinking alcohol, this decision will
mean changing where she hangs out (bars) and the people she hangs out with (drink-
ing buddies). While she knows that drinking has been unhealthy and has caused other
problems, she also knows on some level that it allowed her to avoid facing difficult emo-
tions that stem from an abusive childhood. The secondary gain to drinking for Jane is the
avoidance of deeper emotional work. By giving up her drinking, she is also giving up her

The First Session • 47

safe and established, albeit unhealthy, coping strategy. It can be helpful to acknowledge
to clients that ambivalence is normal and empathize as much as possible what it must feel
like to make changes in their lives.

FINAL THOUGHTS ON THE FIRST SESSION

The first meeting marks the beginning of a big step for clients. Whether the client is man-
dated to receive services or comes voluntarily, starting a change process requires courage.
It is hoped that the first meeting will help the client feel more at ease with this process and
help to engage them in the working relationship when you reflect this sentiment of cour-
age back to them in a genuine and authentic manner. When you show interest in the client
and the client’s particular circumstances and goals, you demonstrate that you value them.
Remember that this work can be challenging and difficult at times, but it is a privilege to
be able to help clients on their path to growth and change.

Ten Tips on Preparing for the First Session

1. Review client information for correct spelling and pronunciation of name.
2. Take a few deep breaths and clear your mind so you can be calm and focused.
3. Have all necessary paperwork with you—​do not forget a pen.
4. Prepare the physical space as best you can for safety and confidentiality. A white noise
machine can be particularly helpful in high-​traffic areas.
5. Have a clock where both you and the client can see it.
6. Smile and keep nonverbal communication neutral.
7. Be aware of body language—​yours and the client’s.
8. Normalize nervousness and difficulty with trust.
9. Leave plenty of time for the client to ask questions.
10. Confirm the next appointment and give the client your contact information.

CHAPTER 5 RESOURCE GUIDE

REFERENCE GUIDE TO CONFIDENTIALITY LAWS
Child Welfare Information Gateway. (2013). Disclosure of confidential child abuse and neglect records.
Retrieved from https://​w ww.childwelfare.gov/​s ystemwide/​laws_ ​policies/​statutes/​confide.cfm
Rape, Abuse, and Incest National Network (RAINN). (2012). Confidentiality laws. Retrieved from http://​
rainn.org/​ p df-​ f iles-​ a nd- ​ o ther- ​ d ocuments/ ​ P ublic-​ Policy/ ​ L egal-​ r esources/​ 2 012/ ​ P rivilege%20
Database%20Summary.pdf
Robert Wood Johnson Foundation. (2012). Health information and the law. Retrieved from http://​w ww.
healthinfolaw.org/​state

48 • Moving Beyond Assessment

US Department of Health and Human Services. (n.d.). Health information privacy. Retrieved from http://​
www.hhs.gov/​ocr/​privacy/​
US Department of Health and Human Services. (nd). Summary of HIPAA Privacy Rule. Retrieved from
http://​w ww.hhs.gov/​ocr/​privacy/​h ipaa/​u nderstanding/​summary/​i ndex.html
US Department of Health and Human Services. (nd). Summary of HIPAA Security Rule. Retrieved from
http://​w ww.hhs.gov/​ocr/​privacy/​h ipaa/​u nderstanding/​srsummary.html

The First Session • 49

 CHAPTER 6

ASSESSMENT

A s mentioned in Chapter 5, in addition to creating a safe working

relationship for the client, you must attend to the task of assessment in your first session.
Assessment is a process that occurs over time with the client, and you are never truly
“done” with it because new information about the client continuously emerges through-
out the work together. Do not be surprised by new information, even in your last session. It
is beyond the scope of this book to explore how assessment differs with families, children,
couples, or other client systems, as this is not a book devoted entirely to assessment, and
therefore it cannot address every issue in a comprehensive manner. This chapter focuses
on assessment of individuals as we introduce you to the language and terms used in a
social work assessment in general, knowing that your role within the agency, the theory
you use, the mission of your agency, and the purpose of the assessment, as well as many
other factors, will all ultimately influence what form your assessment with a client takes.
Our goal here is to help you become familiar with what you may use at some point with
clients and to understand what you may see in reports and treatment summaries when the
assessment was conducted by another professional. This chapter addresses the different
frameworks for assessment, as well as discusses some of their strengths and limitations.
In addition, we aim to help you balance between assessing struggles and challenges and
identifying strengths and resilience.

THE BIO-​PSYCHO-​S OCIAL-​S PIRITUAL

FRAMEWORK
You have heard that social work practitioners use a person-​in-​environment (PIE) perspec-
tive to assess clients using what is referred to as the bio-​psycho-​social-​spiritual framework.
This framework embodies what sets social workers apart from individuals in other disci-
plines. As social workers, we assess all clients holistically. A holistic approach means that
a social work assessment considers how the biological, psychological, social, and the spir-
itual domains all intersect and influence one another. “In this approach, human behavior
is considered to be the result of interactions of integrated biological, psychological, and
social systems” (Hutchinson, 2013, p. 12). In addition, “developments in neuroscience
have generated new explorations of the unity of the biological, psychological, and spiri-
tual dimensions of the person” (Hutchinson, 2013, p. 13). Elements for consideration in
a bio-​psycho-​social-​spiritual assessment are listed in Table 6.1. Social work’s recognition
of the interrelatedness of these domains and the importance of each of these respective
elements sets our profession apart from others. Through this bio-​psycho-​social-​spiritual
framework, social workers look at the whole person within the context of their social envi-
ronment, hence the term person-​in-​environment or PIE perspective.
As part of the holistic perspective, it is essential that social workers assess for both
the struggles and risk factors that the individual(s) is experiencing and the individual’s
strengths and resilience. Within this PIE framework, the total picture of the client’s life is
assessed as social workers aim to understand clients and their needs on multiple levels. It
is through this framework that social workers can assess the challenges clients are facing,
as well as their capacities to manage current and past stressors holistically and therefore
more effectively.
As social work practitioners, we assess for areas of health as well as problems in social
functioning on the assumption that difficulties emanate from the challenge of effectively
managing the internal and external stressors in life. The World Health Organization
(WHO, 2014) stated that

Mental health is a state of well-​being in which an individual realizes his or her own
abilities, can cope with the normal stresses of life, can work productively and is
able to make a contribution to his or her community. (para. 2)

TABLE 6.1: Elements of the Bio-​Psycho-​Social-​Spiritual Assessment

Physical Psychological Social Spiritual

Bodily elements Gender Roles Spiritual beliefs
Diagnoses Sexuality Culture Organized religion
Health concerns Personal experiences Values Values
Genetic predispositions Significant others Economic elements Meaning making
Prescribed physical Habits/​behaviors Race and ethnicity
characteristics,
including sex, race
Abilities and disabilities Relational patterns Community
connections
Timing, such as aging Language Stereotypes
process
Personal history Physical spaces
Access to services
Historical events
Agency setting
Political situation
Institutions
Legal status
National origin

Assessment • 51
The severity of the client’s distress is often a result of the discrepancy between both the
number and the intensity of stressors and the client’s ability to cope effectively. A profes-
sional social work assessment is the process of understanding the client’s situation through
the bio-​psycho-​social-​spiritual framework. These areas of assessment are consistent with
WHO’s (2014) understanding of the determinants of mental health that there are “multi-
ple social, psychological, and biological factors [that] determine the level of mental health
of a person at any point of time” (para. 4).
In addition, another critical task during the assessment phase is to be able to answer
the question, “What is going on?” The answer to this question will determine your prod-
uct, which could be how you will frame the planned change process that you and the client
will begin together, or it could be that the result is a referral to another agency or practi-
tioner. As stated previously, the purpose and outcome of the assessment are determined
by multiple factors.
Each practice setting has its own set of forms and information to gather, but most
follow a general framework of gathering and organizing data on the client’s life history to
formulate a case theory within the context of the current circumstances. In other words,
it is the linking of the client’s past with the present and future that creates a map that
organizes the social work practice by shaping the relationship and communication and
determining the intervention (Bisman, 1994). Therefore, in most settings assessment
includes

• Collecting facts about the client’s past

• Making observations of the client in the present
• Considering the impact of differences and similarities on the client’s life
• Forming hypotheses about the client’s presenting problems
• Formulating questions to test these hypotheses
• Applying theories and models of practice to make inferences about the presenting
problems
• Being aware of your own feelings and reactions in working with this client
• Formulating diagnoses based on the assessment

It is crucial to distinguish between “facts” and judgment. A fact is an observation

stripped of assumptions of meaning or attributions of cause. A fact, for example, is that
a child came to your office for a session with messy hair and dirty clothing with stains.
A judgment, or assumption, is that the child is being neglected. There could be many
alternative explanations regarding the child’s appearance. A thorough assessment pro-
cess helps you answer the question regarding what is going on with the child. If you
jump to a conclusion to answer the question without all of the facts, then you have short-​
circuited the process and run the risk of reaching an inaccurate conclusion. In your
assessment, you may find that the child is going through a developmentally normal stage
of gaining more independence and wants to groom and dress by herself. In doing so, she
did not do a great job of brushing her hair and took her favorite top and bottoms out of
the dirty laundry basket. The parents, in an effort to encourage this independence, chose
not to fight this battle.

52 • Moving Beyond Assessment

A GENERAL FRAMEWORK FOR
FACT GATHERING
The assessment process requires you to organize all data regarding human growth and
development. You must ask questions, listen to the answers, explore complex issues, and
observe the clients. We encourage you to always be curious. The facts that are included
in the assessment will be determined in large part by your setting. What is most salient
for your purposes? Working with young children will require you to obtain a lot of infor-
mation about their early development and family situation. In school settings, you will
be paying particular attention to the factors that relate to educational success. In hospi-
tals and healthcare settings, there will be much more emphasis on physical health factors.
Working with frail older adults will require you to gain more information about cogni-
tive functioning, activities of daily living, and the level of care needed. Facts are gathered
through client meetings, observation, collateral materials (meaning documents from or
conversations with other agencies or professionals), and objective measures, all while
keeping in mind social work values and ethics, strengths, and cultural norms and factors.
In general, you will need to gather information related to these domains:

• Biological/​physical
• Cognitive
• Emotional
• Affective
• Behavioral
• Social
• Familial
• Cultural
• Environmental
• Spiritual/​religious
• Socioeconomic
• Food/​clothing/​shelter
• Medical/​dental
• Vocational/​educational
• Transportation
• Communication
• Child care/​eldercare
• Leisure/​recreational
• Life transitions/​adjustments
• Traumatic experiences
• Interpersonal processes
• Communication issues

It is important that you discuss with your supervisor what specifically he or she would
like you to focus on or emphasize in the assessment process. This will vary by setting and
program focus.

Assessment • 53
 In addition to gathering this information, you should be asking yourself, and the cli-
ent, some form of a Why now? question. Why is this person coming in for help at this par-
ticular point in time? In other words, what prompted the person to seek help now versus
any other previous time? How does the client describe the onset, frequency, intensity, and
duration of symptoms? Finally, explore any previous successful or unsuccessful attempts
to resolve the problem and any other providers and systems involved in helping the client
resolve the problem.

BALANCING STRENGTHS AND PATHOLOGY

Part of the fact-​gathering process is to attend not only to the problems in functioning but
also to the strengths and evidence of resilience. In many cases, what is seen as problematic
behavior now was once adaptive behavior to stressful or traumatic experiences. While
focusing on strengths and resilience, ask yourself the following:

• Where do I see competence, capacity, and courage in this person?

• In what ways does the client focus on the potential possibilities and positive
outcomes?
• What are some creative ways the client is using resources?
• Where do I see a sense of agency and the desire to influence the course of his or
her life?
• Have I seen ways in which the client shows he or she values him-​or herself and has
taken steps toward self-​care?

A thorough assessment focuses on both strengths and challenges, both risk and resil-
ience. Two major perspectives used in social work are risk and resilience (Fraser, Richman,
& Galinsky, 1999) and strengths (Saleeby, 2012). These perspectives ensure that assess-
ment does not dwell solely on the pathology but strives to understand the environmen-
tal contexts that put the individual at risk for these problems in social functioning (risk
factors) and explores the client’s innate capacities (strengths) and ability to bounce back
from adversity (resilience). As practitioners, you need to examine stratification issues of
opportunity, power, privilege, age, gender expression, race, ethnicity, social class, sex-
ual orientation, occupation, as well as physical and mental challenges. These factors are
important in assessment, but if you lose sight of strengths and resilience factors, you are
not seeing a full picture.

ETHNOGRAPHIC INTERVIEWING
A useful tool to ensure that you are not making assumptions during an assessment, and
even beyond this phase, is ethnographic interviewing. As described previously, in a typi-
cal mental health assessment process the practitioner approaches the interaction knowing

54 • Moving Beyond Assessment

that he or she needs to gather facts and data using a set of questions to formulate the treat-
ment plan or any other plan or action. In other words, the practitioner may think, “I know
what I need to know.” In an ethnographic interview, the practitioner follows the client’s
lead as he or she determines what information is necessary to help build an understand-
ing of the client’s situation—​“The client will tell me what I need to know.” Ethnographic
interviewing techniques allow the practitioner to immerse himself or herself into the
unique world of the client to allow for deeper understanding and a more authentic inter-
action (Berry, 2011). This technique allows you and the client to create a space and a lan-
guage with which to speak freely and be understood (Riemann, 2005). In this way, you
are not solely hearing what the client is saying; you are engaging in participant listening,
which allows you take in the values, beliefs, meaning, and context of the client’s world
and, most important, not to make assumptions about the client’s meaning (Forsey, 2010;
Haight, Kayama, & Korang-​Okrah, 2014). When asking questions during an assessment,
the following are some ethnographic techniques:

• Use open-​ended questions rather than yes/​no questions.

• Show interest in the client’s point of view.
• Express your not-​k nowing position and desire to understand the client.
• Restate what the client says by repeating the client’s exact words.
• Summarize the client’s statements and give the client the opportunity to correct
you if you have misinterpreted something that was said.
• Avoid asking multiple questions back to back or multipart questions.
• Avoid leading questions that tend to orient the person to a particular response.
• Avoid using “why” questions because such questions tend to sound judgmental
and may increase the client’s defensiveness.

We hope that you are thinking that these are good interviewing techniques in general.
Yes—​they are. What is different about ethnographic interviewing is the focus on using
global questions and listening for cover terms (Leigh, 1998). Global questions are open-​
ended questions that invite the client to share what the client believes is important for you
to know. An example might be that you have met someone who comes from a different
part of the country or world than you and you would like to know how a particular social
issue, like gay marriage or the disciplining of children, is perceived within his culture.
A global question might be, “I have never met anyone from or been to X Place. Can you tell
me how children are disciplined there?” The client will then tell you from his perspective
about his world.
Cover terms are terms that capture the meaning of the other through language (Leigh,
1998). There are many phrases in American English that would be considered cover
terms, such as “down in the dumps,” “I am beat!” “His hair is sick.” Many of these phrases
are time bound; in other words, they were used at certain periods of time, such as the
term sick. Someone coming from another culture would not know what that means and
could make an assumption that you literally mean that the guy’s hair is not feeling well,
which would not make any sense. When using ethnographic interviewing, rather than
letting such a phrase go by, even if you think you might know what it means, you would
come back to that question and ask the individual what he or she means by that phrase.

Assessment • 55
The client’s meaning is what is important, and by listening for cover terms, you can be
more attentive to those phrases without making an assumption about what the client
is trying to communicate. The client’s description of the cover term is referred to as the
descriptors (Leigh, 1998). These descriptors help to express the meaning that the client is
hoping to communicate.
Using ethnographic interviewing, the interviewer provides a summary of what he or
she has heard from the client and, most important, what he or she has learned at the end of
the interview. This part of the process helps communicate the message to the interviewee
that the interviewer has been a beneficiary of the process. The closer statement also rein-
forces that the interviewer is a learner in this process rather than the expert.
It is worth mentioning two important final statements about ethnographic interview-
ing. The first is that this technique is meant to demonstrate that the interviewer is a stu-
dent of the interviewee’s experience only. We would never want the interviewee to feel that
he or she was representing an entire group, as some individuals historically have felt they
were being asked to do. In ethnographic interviewing, the interview is designed to explore
one person’s experience and how that person may make meaning of that experience.
The other important message we want to give about this technique is that it is a tool
that can be used with every client and in every stage of your work with clients. It should
not been seen as a technique that is used only when we perceive that someone is different
from us. We have personally experienced this and have heard from other social work col-
leagues that they have also made false assumptions about clients who they perceived to
be similar to themselves due to demographic or geographic similarities. Every client has
a unique story, and it benefits us all when we do not make assumptions that we know the
client’s story without fully exploring it and consistently taking the stance of not knowing.
By adopting ethnographic interviewing as the foundation for your interviewing style, you
will be more likely to avoid assumptions and listen with a more open ear to those unique
stories offered by your clients.

ASSESSMENT AND SCREENING TOOLS

In general, there are many tools that can be used by social workers in the assessment pro-
cess. As with everything in our field, there are pros and cons to each of them. At the risk
of being too repetitive, check in with your supervisor to be sure you understand the needs
of your agency. This will help you identify and then utilize the most appropriate tools
in your setting while avoiding asking clients questions they have already answered for
your agency. When engaging mental health services, clients can often feel overwhelmed
and exhausted by repeating information and answering the same questions over and over
again. By asking, what information you really need now and what you can gather over
time, you can avoid bombarding the client with questions.
Assessment and screening tools are designed to help practitioners gather information
efficiently, but as a result, much information can be lost when they become the primary
tools or focus of the interview. In addition, it is important to assess the appropriateness of
each tool given the client’s unique presentation and identities, as some tools may not be

56 • Moving Beyond Assessment

appropriate given someone’s cultural, educational, or diagnostic background. As we can-
not discuss each of these in depth, our goal here is to introduce you to some general tools
that are commonly used in our field so that you are familiar with them and could practice
using them if appropriate for your setting.

SOCIAL FUNCTIONING PICTOGRAMS

Social workers often use social functioning pictograms, the most common being the geno-
gram and the ecomap (Sheafor & Horejsi, 2011). A genogram is a pictorial representation
of ideally three or more generations of a family system. It is a visual representation of the
biological, legal, and family structure or system. It is helpful for recording pertinent family
information, such as demographic data, as well as functional information such as medical
(i.e., health issues like diabetes), emotional (i.e., histories of depression), and behavioral
functioning (i.e., use of substances or history of incarceration). Finally, it is useful for delin-
eating family relationships, such as particularly close bonds between members, and rela-
tionships that are estranged or full of conflict. When working with families in which there
are patterns of intergenerational trauma or histories of mental illness, a genogram can help
you and the client track the history and patterns throughout a family’s history to understand
where it began and how to intervene in these cycles. Every genogram should include a key to
help anyone looking at it understand the meaning of each symbol used to express a pattern.
An ecomap is a pictorial representation of the client within the client’s social con-
text. Often, the genogram is placed in the center of the ecomap when working with
children and families. The ecomap provides a blueprint for understanding the PIE per-
spective (Sheafor & Horejsi, 2011). What is the lived experience? In other words, what
are the communities to which the client is connected? Are there other personal, social,
psychological, and spiritual influences in the client’s life? Where are the resources and
natural helping networks with which the client already interacts? The ultimate purpose
of an ecomap is to give a visual image of the social supports available to the clients.
Similar to a genogram, the ecomap should have a key to help decipher the meaning of
each of the symbols.
You can see examples of genograms and ecomaps in most social work practice text-
books if you are not familiar with them already. Depending on your setting and your time,
you may choose one over the other in an effort to gather particular information in the
assessment. It is hoped that comparing both of these tools demonstrates how each pro-
vides useful information about the clients and yet, with each of them, other information
captured by the other is lost. You must decide which instrument is appropriate given your
goals in the assessment.

MENTAL STATUS EXAM

An assessment tool commonly used by medical and mental health practitioners in a wide
range of settings is the mental status exam (MSE). This quick assessment tool allows you
to note observations about the client in the following areas:

Assessment • 57
 1. Appearance—​general observations about age, gender, ethnicity, and physical
appearance, as well as hygiene, mannerisms, and so on.
2. Mannerisms and approach—​practitioner’s experience of the client as they engage
in the process of the assessment; the client’s manner of interaction, eye contact,
expressions, as well as rate and volume of speaking.
3. Emotions—​observations of mood and affect with regard to range and appropri-
ateness. This is also where you would explore suicidal and homicidal ideation,
risk of violence, impulsivity, and other potentially dangerous emotions and
behaviors.
4. Thought processes, content, and orientation—​T his part of the exam is where
you explore cognitive functioning (orientation to person, place, and time);
coherence of speech; ability to attend to and follow the thread of the dis-
cussion; the presence of any hallucinations or delusions; and intellectual
ability.
5. Insight and judgment—​evidence of the client’s awareness of their situation and the
ability to predict consequences of behaviors to make safe and healthy choices
(Corcoran & Walsh, 2014).

The main goal of an MSE is to provide a quick snapshot of the person in the present
moment. It is meant to be mainly descriptive, as if looking at a picture, not about infer-
ences or judgments. This picture can then be compared to other points in time, which can
be useful when trying to identify whether someone’s functioning has changed. For exam-
ple, an MSE is often conducted at the time of admission to a hospital or other setting. One
would hope that through the services provided at the agency, the client would improve. By
comparing the MSE at intake to the MSE after a certain time frame, the practitioners can
assess whether there has been improvement in certain domains. Similarly, if a client is at
risk of a rapid decline, such as someone with a form of dementia, the MSE conducted on a
certain day can be compared to the last month’s and the one that was conducted 6 months
previously. Such information can be vital in understanding the stability or instability of
someone’s mental state or functioning.
Of course, the MSE is flawed like all other tools. It only includes a limited amount of
information, and there is a risk of different practitioners judging certain areas differently,
in spite of every effort to make this process as judgment free as possible. Therefore, as with
everything in our field, it is always worth obtaining a consultation or a second opinion and
to gather additional information so you do not make a judgment about someone based on
one specific source of information.

STANDARDIZED INSTRUMENTS
In addition to the general assessment tools, there are many screening tools that are used
for specific issues, such as depression, anxiety, and trauma. (See Chapter 15 on evaluation
for some additional discussion on the use of standardized instruments as tools for eval-
uating intervention outcomes.) They are referred to as standardized instruments, which
“have uniform procedures for administration and scoring and are accompanied by certain

58 • Moving Beyond Assessment

kinds of information, including data concerning reliability, validity, and norms (average
scores of certain groups)” (Gambrill, 2013, p. 395). They are used to:

(1) Describe populations or clients; (2) screen clients (e.g. make a decision
about the need for further assessment or find out if a client is eligible for or likely
to require a service); (3) assess clients (a more detailed review); (4) evaluate
progress; and (5) make predictions about the likely futures of clients. (Gambrill,
2013, p. 395)

In general, these instruments have been evaluated to measure a particular con-

struct, such as those listed, and to give a score that indicates an affirmation of the pres-
ence of a disorder and often its severity. They are, in theory, designed to take the bias
out of both a client’s self-​a ssessment and the practitioner’s evaluation. A client’s score
on such an instrument can then be compared to “the standard” so that the practitioner
and client can see how the client’s score compares to either the general population or
others who are similar, based on a demographic characteristic, such as age, gender, or
ethnicity.
While they can be useful to clients and practitioners because they provide a bench-
mark for the presenting problem and can also ensure that the practitioner has asked
questions that will capture the essence of the issue, they also have drawbacks. One in par-
ticular is that these instruments are often normed using populations that are convenient
to the developer of the instrument (Drisko & Grady, 2012). For example, the developer
is often an academic who uses college students as the normative population. Depending
on where the person is located, this group of college students may or may not accurately
represent the general population in terms of diversity, levels of functioning, and many
other differences. Therefore, it is important to learn about the instrument with regard to
the populations with which it was tested and how closely the populations resemble your
client. Remember, different cultures express different struggles very differently (Lambert
et al., 2005; Lambert, Markle, & Bellas, 2001).
Another important consideration is the impact the assessment might have on the per-
son’s self-​perception. For some clients, knowing that they are “clinically depressed” gives
a label that is helpful in that it captures their experience, and they can now search for
resources and answers. For others, such a label can be damaging as they may see them-
selves as damaged and flawed, which increases their depression. Therefore, it is important
to consider why you might use an instrument and the impact such information might
have on your client.
Finally, these instruments are designed to measure one construct, such as depression,
trauma symptoms, or developmental achievements. It is worth noting that, as a result,
they are limited—​they assess only one aspect of the person.
Many standardized instruments are protected by copyright, but others are open
access and can be found in books or on websites (see the Summary Guide for more
information). Some specific tools require training to learn how to administer and
score, while others are self-​administered by the client and relatively easy to score. Your
supervisor can help you determine which ones are appropriate for your setting and
your client population.

Assessment • 59
PSYCHOLOGICAL TESTING
There will be times when you will need to refer clients for psychological testing or assess-
ment to determine if a specific diagnosis or problem in social functioning is present.
Although social workers regularly conduct diagnostic assessments in their work with cli-
ents, some cases are more complex due to neurological issues or medical concerns that
might make the diagnostic picture a bit murky and unclear. Also, there are times when
clients are seeking specific information that is outside our expertise. In such cases, it can
be helpful to have another professional who is trained in administering specific diagnos-
tic and assessment instruments to parse out the complex issues or provide you and your
clients the information that they need to plan for an intervention.
Most often, for nonmedical assessments, social workers use the expertise of licensed
psychologists who are trained to conduct the type of assessments described. We recom-
mend that you ask within your agency or identify on your own competent psychologists in
your community who can offer such services when needed. For example, you may be work-
ing with a child who wants to attend a private school that requires an IQ test. This test will
most likely be part of a battery of tests that are administered by a psychologist. There are
also personality tests (e.g., the Minnesota Multiphasic Personality Inventory), behavioral
assessments, achievement tests for work, career-​planning assessments, and many others
that are used for a variety of purposes. There are tests to measure depression, anxiety, post-​
traumatic stress disorder, and a host of other problems in social functioning (Kline, 2013).
Finally, one specific reason to refer clients to a psychologist for testing is to conduct
a neuropsychological test. This would be necessary if you need to obtain a measure of
cognitive functioning in situations where you are working with someone who has had
damage to the brain due to an accident, abuse, athletic injuries, or military service. These
tests are often a crucial part of formulating a comprehensive assessment of your client,
and you will need to work with the psychologist administering the test to be sure you
receive an interpretation of the results for use in creating an appropriate course of treat-
ment. Psychologists who conduct neuropsychological testing have specialized training
to look at brain functioning; therefore, it is important to refer to the appropriate person
depending on the information that you are seeking.

CLASSIFICATION SYSTEMS
Depending on your setting, a main component of an assessment might be to develop a
mental health diagnosis. As you gain more experience in this work, this part of the assess-
ment process will become easier. However, it is always important to consult a reputable
classification system of mental health disorders, such as the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-​5), published by the American Psychiatric
Association (2013); the International Classification of Diseases, Tenth Revision (ICD-​10),
which was put out by WHO (1992); or the theory-​driven Psychodynamic Diagnostic
Manual (PDM), created by a number of psychoanalytic groups (PDM Task Force, 2006).

60 • Moving Beyond Assessment

 Whichever classification system you use, it is important to be aware of the cultural
influences of these manuals and the way in which your client’s culture will play a role
in discerning what is “normal” and “abnormal” behavior (Lee & Kleinman, 2007). All
labels or diagnostic conditions are social constructions derived by the culture from which
they originate. Conrad asserted, “Illness and diseases are human judgments on condi-
tions that exist in the natural world” (as cited by Heller & Gitterman, 2011, p. 6). Some
individuals who study the cultural influences on diagnoses believe that “culture shapes
the way general psychopathology is going to be translated partially or completely into
specific psychopathology” (Lee & Kleinman, p. 29). The importance of evaluating the
impact of cultural influences in our work with clients is discussed further in Chapter 3.
In spite of the potential cultural limitations, these manuals attempt to organize research
and practice information about clinically significant behavioral or psychological patterns
that occur in individuals in a way that causes problems in social functioning or psycho-
logical distress and is not culturally expected or anticipated. These categories of disorders
are offered to create consistency across practitioners in the identification, diagnosis, and
treatment of mental health disorders.
Despite these strengths, it is also important to consider the impact of such labels
on the individuals with whom we work. For example, it is essential that we always use a
“person-​fi rst” approach when discussing clients who have been diagnosed or labeled in
some way (Heller & Gitterman, 2011, p. 6). A person-​fi rst approach means that we say “the
person with schizophrenia” versus “a schizophrenic,” which leaves out the fact that there
is even a person in the discussion. Therefore, it is important to remember that “all people
maintain multiple identities and describing an individual by the name of their ‘disorder’
or ‘condition’ elevates that condition to a primary descriptor, potentially obscuring both
the complexity and essence of a human being” (Heller & Gitterman, p. 6).
Depending on your professional training and experience, you will become aware of
these debates and others that exist in particular professions regarding the use of classifi-
cation systems. For example, many social workers have criticized the DSM for being too
focused on pathology and not strengths based (Probst, 2013; Wakefield, 2013). This cre-
ates a conflict for these professionals, as they must come up with a DSM diagnosis for use
in assessments as well as for insurance reimbursement of services. One alternative that
has been created to the medical model classifications systems like the DSM and ICD is
the Person-​in-​Environment System Manual (Karls & O’Keefe, 2008). This manual is seen
as more in line with social work values and places the client in the context of his or her
environment. It also offers open-​source assessment forms. Unfortunately, the PIE has not
been well developed in the literature or adopted widely by mental health professionals in
the field (Kondrat, 2008).

FINAL THOUGHTS ON ASSESSMENT

Remember that assessment skills take time to develop. As new practitioners, you are
just starting to develop this knowledge, skill, and confidence. You are never actually

Assessment • 61
finished with the assessment process, even though you may have completed an assess-
ment product. The client situation is constantly changing. Learn to be comfortable with
an ever-​changing landscape and be open to new information that will change the course
of the work.

CHAPTER 6 RESOURCE GUIDE

SCREENING TOOL REFERENCES AND WEBLINKS
TO HELPFUL ASSESSMENT RESOURCES
American Psychiatric Association (APA). (2014). Online assessment measures. Retrieved from http://​w ww.
psychiatry.org/​practice/​dsm/​dsm5/​online-​assessment-​measures#Disorder
CSWE Gero-​Ed Center. (2014). Differential mental health assessment course materials. Retrieved from
http://​w ww.cswe.org/​CentersInitiatives/​CurriculumResources/​M AC/​GIG/​SLU/​36890.aspx
International Society for Traumatic Stress Studies (ISTSS). (2014). Assessing trauma: Assessment resources.
Retrieved from https://​w ww.istss.org/​assessing-​t rauma.aspx
Michigan State University: School of Social Work: Koehler for Mental Health Professionals. (2003–​2012).
Assessment tools. Retrieved from http://​socialwork.msu.edu/​koehler/​for_​m h_​professionals/​forms.php
Military Pathways. (2014). Military mental health screening program. Retrieved from https://​
mentalhealthscreening.org/​programs/​m ilitary/​resources/​a-​d ifferent-​k ind-​of-​courage.aspx
PAR, Inc. (2012). Mini-​Mental State Examination (MMSE®). Retrieved from http://​w ww4.parinc.com/​
Products/​Product.aspx?ProductID=MMSE
SAMSHA-​H RSA: Center for Integrated Health Solutions. (n.d.) SBIRT: Screening, brief intervention, and
referral to treatment. Retrieved from http://​w ww.integration.samhsa.gov/​c linical-​practice/​sbirt
SAMHSA-​H RSA: Center for Integrated Health Solutions. (n.d.). Screening tools. Retrieved from http://​
www.integration.samhsa.gov/​clinical-​practice/​screening-​tools
SMH: Screening for Mental Health. (2010). Our programs. Retrieved from http://​w ww.mentalhealth-
screening.org/​programs/​
Teen Mental Health. (2014). Clinical tools. Retrieved from http://​teenmentalhealth.org/​for-​health-​
professionals/​clinical-​tools/​

62 • Moving Beyond Assessment

 CHAPTER 7

ASKING THE DIFFICULT

QUESTIONS
What to Ask and How to Respond

N ew practitioners struggle with asking questions that can feel intrusive

and personal. In addition, sometimes new practitioners may be afraid of what the answers
to the questions might be and doubt their ability to respond effectively to the answers
given by their clients. For example, many new clinicians are afraid to ask clients about
their thoughts of suicide, believing that by asking the questions they will increase the
likelihood of that person thinking more about it. In reality, there are real negative conse-
quences of not asking such questions. To assuage such concerns, this chapter explores why
these questions must be asked and debunks some of the myths of the risks associated with
asking them. Examples of how to phrase such questions are offered in an effort to reduce
the feelings of intrusiveness.

WHY MUST I ASK THESE QUESTIONS?

There is a scene in the movie Kissing Jessica Stein in which Jessica is talking with Helen
about questioning her sexual identity:

Helen: “What does your therapist say about all of this?”

Jessica: “Oh I could never tell my therapist.”
Helen: “Why not?”
Jessica: “Because it’s private!”

This scene epitomizes the difficulty clients can have in feeling comfortable enough
with us to discuss sensitive issues, even when they know that the information that is
shared will be kept confidential. We also can feel uncomfortable asking a client personal
questions or exploring difficult issues unless the client brings them up. These feelings of
discomfort could easily lead to an impasse, with both client and practitioner waiting for
the other to open the dialogue. Therefore, it is incumbent on us to ask the difficult ques-
tions to demonstrate to the client that we feel comfortable discussing these topics. The
client can always decide that he or she is not ready to explore these issues or that there
just might be nothing of significance to discuss. Yet, it is important to communicate that
if there is a topic area that might be of significance to the client, you are comfortable
exploring it.
When the practitioner asks the questions, it does three things. First, you are nor-
malizing the concern. This normalization lets the client know that other people have
concerns about these issues and that your work together is an acceptable forum in
which to discuss them. Second, you are breaking the silence and any taboos about
these topic areas. Many of us received messages from our families and our social set-
tings that we do not “air our dirty laundry” or discuss difficult or personal matters in
“polite company.” The helping relationship is different, as this relationship may be the
one where you do discuss these matters. We need to communicate that, within this
relationship, these conversations are acceptable, and that providing a forum for these
discussions is exactly what the relationship is for. We need to give the client permis-
sion to use the relationship if the client needs this kind of “space.” Third, by asking
these questions, we are directly confronting any shame the client may be carrying
from not being able to talk about a subject. Shame is often the most significant barrier
to discussing difficult issues. By giving clients an opportunity to talk about the topics
about which they have feelings of shame, we hope to break down barriers built by their
feelings of shame.
Not asking these questions can have some unintended consequences. Silence can send
a message that you do not want to talk about sensitive matters. By avoiding questions
that relate an experience (e.g., sexual abuse), it is possible that the client may interpret
your silence as your way of letting him or her know that you would be too upset by a dis-
closure and cannot handle discussions related to these experiences. Another potential
unintended consequence is that by remaining silent you may remind the client of others
in his or her life who minimized or dismissed these issues, which can have an impact on
feelings of trust and safety in the relationship. Finally, you may inadvertently convey to
the client that he or she must continue being silent on these matters, leading the client to
the conclusion that there is no safe place to discuss them.

MYTHS AND FACTS ABOUT ASKING

DIFFICULT QUESTIONS
One of the reasons new practitioners do not ask questions about suicide, self-​injury, abuse,
and other sensitive topics is that they often hold misconceptions about what these behav-
iors mean or what the discussion will stir up in the client. Some common myths, and the
more accurate understandings of these dynamics, are presented next to help you feel more
comfortable asking these types of questions:

64 • Moving Beyond Assessment

Myth: If I ask clients if they have thoughts about killing themselves, it will give them the
idea that suicide is a way out of their pain.
Fact: When someone is not suicidal, you cannot “suggest” suicide as an idea by asking
if they have thoughts about it. It is important to remember that when someone is having
thoughts about ending their life, it can be helpful to discuss them and to explore other res-
olutions to the pain they are currently experiencing. It is also important to obtain infor-
mation about previous suicidal periods and about any past attempts (Jamison, 1999).
Such information will tell you about how lethal their attempts were and how they coped
with such feelings in the past.

Myth: Asking a client if they have a history of sexual or physical abuse can cause a post-​
traumatic reaction in clients.
Fact: You can ask about whether a person has ever experienced abuse in the past without
going into the details. If the client does have an abuse history or is currently experienc-
ing abuse, you should proceed with great care in asking them to relate details or share
memories. Practitioners who work with trauma survivors advocate for trauma-​informed
treatment approaches that lay the groundwork for coping skills to help the client man-
age the traumatic memories before sharing the narrative of the experiences (Courtois &
Ford, 2012).

Myth: A client who self-​injures is suicidal, so if I ask about their self-​inflicted injuries,
then I may be required to have them hospitalized.
Fact: There is a difference between self-​injurious behavior and suicidal intent. Most
people who inflict injury on themselves do not intend to end their life. Behaviors such
as skin picking, hair pulling, and cutting or burning skin are often done in an attempt
to relieve intense feelings. Such behaviors can be best understood as a coping mecha-
nism to distract from or avoid feelings associated with distress or traumatic experiences
(Walsh, 2006).

Myth: If I ask a client who is in recovery from substance abuse to discuss their history of
use or desire to use again, it will cause a relapse.
Fact: Much like questions about suicidal feelings, discussing past problematic sub-
stance use or desire to use again does not cause clients to relapse. In fact, by helping
clients discuss what causes them to feel like using (triggers), they can explore alter-
natives to that behavior. These discussions can help the client avoid relapse. Most cli-
ents who have already been through substance abuse treatment are open and honest
about past behaviors and are invested in maintaining their sobriety (Witkiewitz &
Marlatt, 2004).

Myth: If a client does not report problematic substance use, then you do not need ask any
further questions about this.
Fact: If a client is using drugs or alcohol to cope with their distress, or if their use if
feeling out of control, they may not be honest with themselves or with you about their
current use. It is always important to explore if and how a client uses alcohol, illegal
drugs, or prescription drugs and assess whether this use rises to the level of a substance
use disorder (Tanner, Wilhelm, Rossie, & Metcalf, 2012).

Asking the Difficult Questions: What to Ask and How to Respond • 65

ASKING THE QUESTIONS
As you begin to develop your own style of how to ask these questions, we offer you a few
suggestions about how to approach these discussions and ways to handle disclosures.

TRAUMA HISTORY
Approaching the issue of trauma from a broad lens can be helpful in determining if
the client has experienced significant life events that have overwhelmed his or her nor-
mal capacity to cope. Trauma is a subjective experience—​what feels traumatic to you
might not to someone else. One approach is to ask: “Have you had any experiences,
recently or in the past, where you feared for your safety?” Or, you can ask: “Can you
think about a time in your life when you felt overwhelmed by what was happening and
unable to cope?”
If a client reports having experienced a traumatic event, you can let the client
know that you are glad they felt comfortable telling you and that together you can
work on exploring this experience when they feel ready. To ask specifically about sex-
ual abuse trauma, you can ask, “Has anyone ever touched you in a way that made you
feel uncomfortable?” or “Have you ever felt forced to do something sexual that you
did not want to do?” You may be the first person who has ever asked these questions
or the first person with whom the client has chosen to share this information, so be
sure to respond to the disclosure with care and concern, using statements such as the
following:

• “I’m very glad you told me about this.”

• “I appreciate your willingness to share this difficult experience with me.”
• “This never should have happened to you; I’m very sorry it did.”
• “If you want to explore this in our work together, we can do that when you are
ready.”

If you do not feel able to help the client process these experience or if it is beyond the scope
of the services in your practice setting, be sure to have referrals on hand to direct the client
to someone who can help them. National and international resources can be found in the
chapter summary guide.

SUBSTANCE ABUSE
There are various cultural norms concerning drug and alcohol use, and our own
experiences may inform how and if we ask questions about substance use. However,
asking clients about their use of alcohol as well as prescription and nonprescription
drugs is crucial, as use of substances may be a sign of other struggles and can lead to a
number of concerns related to physical and mental health, as well as social well-​being
and functioning. It can be difficult to “unravel” the threads of the mental illness and

66 • Moving Beyond Assessment

the effects of the substances, and trying to do so can feel like trying to answer that
age-​old question: Which came first, the chicken or the egg? Substance use can some-
times mask or alter the information related to other issues with which the person is
struggling. For example, interactions with prescription medications can often com-
plicate treatment and make it difficult to obtain a baseline of the client’s functioning.
Trying to treat an issue without understanding the full picture can make any inter-
vention less effective.
When working with clients who are using alcohol and prescription or nonprescrip-
tion drugs, it is essential to consider in your assessment process the potential impact
these substances are having on brain functioning, emotional well-​being, and their abil-
ity to be attuned with others in their lives, including you. Alcohol and other substances
have an impact on the functioning of the brain’s limbic system, cerebral cortex, and
prefrontal cortex (Farmer, 2014). For more on the brain and neurobiological processes,
see Chapter 18.
Clients who have both a substance use disorder and a mental health disorder are
referred to as having a “dual diagnosis”; unfortunately, this combination is common in
many of the populations social workers encounter (Drake & Mueser, 2000). Dual diagno-
sis treatments focus on addressing both substance use and mental health issues and com-
bine or integrate mental health and substance abuse interventions. Integration involves
not only combining appropriate treatments for both disorders but also often modifying
traditional interventions. For example, social skills training interventions emphasize not
only the importance of developing relationships but also the need to avoid social situa-
tions that could lead to substance use. Substance abuse counseling goes slowly, as there
are multiple layers of challenges the client is facing related to both the mental illness and
the impact of the substance use disorder. The goal of dual diagnosis interventions is recov-
ery from two serious illnesses. In this context, recovery means that the individual with a
dual diagnosis learns to manage both illnesses so that he or she can pursue meaningful life
goals (Drake & Mueser, 2000).
To determine whether your client has a substance use issue, you must ask difficult
questions that require the client to honestly evaluate whether his or her use has risen to
problematic levels. Some questions to consider are the following:

• “Can you tell me about your use of alcohol, drugs, prescription medication, or
other substances?”
• “Have there been any negative consequences from your use?”
• “Has anyone expressed concern regarding your use?”
• “Are you concerned about any behaviors that feel out of control?”

If these questions yield a disclosure about problematic use, respond with concern for the
client’s well-​being and safety without shaming or chastising the client. There are many
cultural stigmas concerning those who abuse substances, and you may hear others,
including your colleagues, use derogatory terms to refer to clients such as “drug addicts”
and “alcoholics.” Not only are such phrases derogatory, but also they do not demonstrate
respectful, person-​fi rst language (Heller & Gitterman, 2011). Such language often perpet-
uates society’s negative views of individuals who struggle with substances, creating more

Asking the Difficult Questions: What to Ask and How to Respond • 67

barriers for clients who struggle with being honest and open about these issues. To convey
your empathy, consider a response like the following:

“Many people turn to drugs or alcohol to cope with stress. It seems like it worked for you for a
while, but now it’s not. Would you be open to talking more about how to find other ways to
handle life’s stress?”

Once you receive agreement from the client, you can then link them to some resources.
The ones in the chapter’s summary guide are a good place to start.

RELIGION AND SPIRITUALITY

A person’s religious or spiritual practices are personal. We often do not discuss religion
or politics in social settings because they can raise areas of conflict and differences of
opinion between people. Practitioners who do not ask about a client’s spiritual prac-
tices are often missing a big dimension of the person’s life experience (Cunningham,
2012). If they are not religious or spiritual, that is also okay. But if you do not ask,
you might never know. When you ask a client if they have a faith tradition or spiritual
practices, it can open up a wealth of information about family history or how he or
she makes meaning out of events, as well as provide a potential source of support or
strength. Also, be aware that while for many clients their faith traditions are sources of
comfort and pride, for others this topic may be an area of internal conflict. For some,
faith traditions can be experienced as contributing toward feelings of shame or iso-
lation due to a variety of factors. Therefore, it is important not to get into a discus-
sion about your own personal beliefs or practices but to focus on your client. Should
the client ask you about your own spiritual beliefs, it is important to explore why he
or she is seeking to know this information so that you can best understand how to
respond. It is a good idea to talk about these potential responses with your supervisor.
For those social workers working at a faith-​based organization, these issues may arise
more often. As such, it is even more important to discuss with your supervisor how
such conversations are handled at the agency.
When exploring spiritual practices or religious traditions, remember that these per-
sonal dynamics can change over time as the client grows and develops. Consider ask-
ing: “Does your family practice a particular religion?” You also want to follow this up with
questions about changes in these practices over time. You can ask: “Have your beliefs or
practices changed over time?” and “How does your spirituality influence your daily life?”
If the client wants to tell you about his or her practices and beliefs, it is essential that your
responses are nonjudgmental and affirming.

SEXUALITY
As noted with the scenario in the beginning of this chapter, it is normal for people to feel
reluctant to engage in conversations about sex and sexuality. Your comfort level with

68 • Moving Beyond Assessment

asking questions about this dimension of human experience will depend on your own
feelings about your sexuality and about having these discussions with others. You may
want to spend time role-​playing or practicing asking these questions with others with
whom you feel comfortable to increase your skills. You can open up a dialogue by asking
a general question: “Are you currently sexually active?” or “What sexual problems or
concerns have you experienced?” This can begin a discussion about the client’s sexual
self. By asking a question such as “Overall, how would you describe your sex life?” you
can also explore the level of satisfaction or dissatisfaction with this, along with any con-
cerns about sexual health and well-​being. It is possible that during this discussion, clients
may chose to disclose any history of sexual trauma, so it is best to be prepared for such
disclosures as well.
When exploring a client’s sexuality and sexual health, you will often arrive at dis-
cussions regarding sexual orientation. If this does not arise naturally, you may need
to ask a specific question, such as “How do you identify your sexual orientation?”
Sexual orientation is on a continuum and can be f luid over the course of the person’s
lifetime, so you can also ask about any changes in sexual orientation over the life
course. Be prepared for disclosures from a client who is grappling with sexual orien-
tation. A client may tell you that they are unsure about their identity or that they are
in the process of coming out and you are the first person they are talking with about
it. Respond to any disclosures in affirming and normalizing ways. Statements such as
“I am glad you felt safe telling me this” and “Many people find themselves question-
ing their sexual orientation over time” can reassure them that you are someone they
can talk to. See the chapter’s summary guide for resources for yourself, the client, and
the client’s family members.

SELF-​H ARMING BEHAVIOR AND SUICIDAL

FEELINGS AND ACTIONS
Asking clients about self-​harming behaviors can feel complicated for many reasons.
Primarily, we can feel unsure about the severity of the behavior, as it can be difficult to
differentiate between self-​harm and suicidal intention. As noted in the myths and facts
presented previously, distinguishing between a self-​harming behavior and a suicide
attempt helps practitioners obtain a sense of what the client needs. Identifying the differ-
ences between these two behaviors requires us to ask difficult questions about distress,
self-​injury, and any suicidal feelings and intentions.
You can begin to differentiate between these two by focusing on what is causing the
behavior and what the client is intending in the outcome. People engage in self-​injurious
behaviors because of overwhelming intrusive thoughts or feelings; here, the desired
outcome is relief from psychological distress or distraction from the unbearable affect
(Walsh, 2006). Suicidal thoughts or feelings, on the other hand, typically stem from a
sense of despair and hopelessness; the person is unable to see any resolution to the psy-
chological and emotional pain he or she is experiencing. In these situations, the desired
outcome is to end one’s life to make the pain stop.

Asking the Difficult Questions: What to Ask and How to Respond • 69

 Questions about self-​injury and suicidality should be both direct and empathic.
Consider asking the following:

• “What do you do when your thoughts and emotions feel unbearable?”

• “Have you ever inflicted an injury on yourself?”
• “Do you ever cause yourself physical pain to alleviate emotional pain?”
• “Have you ever had thoughts about ending your life?”
• If yes—​“Have you ever acted on those thoughts?”
• If no—​“ What keeps you from acting on those thoughts?”
• “How many times in the past have you tried to end your life?”
• Ask follow-​up questions here to gain information about the lethality of the methods
used, for example, “What was the method by which you tried to end your life?”
• “Can you tell me about a time in your life where living felt unbearable?”

These questions are asked in an effort to understand the client’s unique experiences of self-​
harm or suicidal feelings. Respond to disclosures calmly, demonstrating your concerns
about your client’s safety. If you convey a sense of fear or alarm, you will inadvertently send
the client the message that you cannot handle these discussions. It is important explore
multiple options regarding their next steps. Many clients may fear that you will insist that
they be hospitalized, yet in most cases, self-​injury does not require hospitalization. For
clients who are suicidal, there is a difference between discussing feelings on which they do
not intend to act and having a specific plan with lethal means on which they intend to act.
These issues regarding client safety are explored in depth in the next chapter.

FINAL THOUGHTS ON ASKING

DIFFICULT QUESTIONS
Asking these difficult questions may feel awkward at first, but as you have more prac-
tice, you will develop your own style that will feel natural and authentic to you and fit
with your personality. Not asking these questions leaves crucial gaps in your assess-
ment and therefore your treatment plan. It is often the practitioner’s own concerns
about his or her ability to effectively handle the answers to these questions that create
a barrier as well as concerns about the questions feeling intrusive to the clients. The
summary guide at the end of this chapter provides you with resources to help with
these concerns. Remember, if you do not ask, not only will you not have the full pic-
ture of your client’s situation, but also you may inadvertently communicate that such
topics are uncomfortable or unacceptable in the relationship you have formed with
your client. Therefore, it is critical that you explore, in supervision or in other forums,
your own challenges with asking questions about difficult topics and find ways to com-
municate your openness and willingness to explore topics further. Your comfort with
such topics will set the stage for a much more productive and it is hoped more effective
relationship with your client.

70 • Moving Beyond Assessment

CHAPTER 7 RESOURCE GUIDE: LIST
OF RESOURCES
CHILD ABUSE
http://​w ww.nationalchildrensalliance.org
National Children’s Alliance®: National resources
1-​800-​4 -​A-​CHILD or http://​w ww.childhelp.org
National Child Abuse Hotline: National hotline for reporting, resources, and
services

DOMESTIC VIOLENCE
http://​w ww.thehotline.org
National Domestic Violence Hotline: Online chat forums with domestic violence
experts and counselors
1-​800-​799-​SAFE
National Domestic Violence Hotline

RAPE AND SEXUAL ASSAULT

https://​w ww.rainn.org
Rape, Abuse, and Incest National Network: Online hotline and national
resources
1-​800- ​656-​HOPE
National Sexual Assault Hotline

SELF-​INJURY
http://​self-​injury.net
National and international support communities
1-​800-​DONT CUT
Information line for national resources

SEXUAL ORIENTATION AND GENDER IDENTITY

http://​w ww.matthewsplace.com/​hotline/​glbt-​national-​youth-​talkline
Matthew’s Place: National resources for gay, lesbian, bisexual, transgendered, and
questioning youth
1-​800-​850-​8078
National Youth Support Line
http://​w ww.glnh.org
GLBT National Help Center: Free peer support and national resources for adults
and youth

Asking the Difficult Questions: What to Ask and How to Respond • 71

 http://​w ww.befrienders.org
Befrienders Worldwide: International resources regarding sexual orientation and
gender identity
1-​888-​843-​4564
GLBT National Hotline

SPIRITUAL ASSESSMENT
Canda, E. R., & Furman, L. D. (2010). Spiritual diversity in social work practice: The
heart of helping (2nd ed.). New York, NY: Oxford University Press.

SUBSTANCE ABUSE
http://​fi ndtreatment.samhsa.gov
Behavioral health treatment services locator: National resource for treatment
programs and listing of self-​help resources such as AA (Alcoholics
Anonymous) and NA (Narcotics Anonymous)
1-​800-​662-​H ELP
National Helpline for Substance Abuse

SUICIDE
http://​w ww.suicidepreventionlifeline.org
National Suicide Prevention Lifeline: Support in the United States
1-​800-​273-​TALK
National Suicide Prevention Lifeline toll-​f ree number

72 • Moving Beyond Assessment

 CHAPTER 8

ASSESSING THE SAFETY

OF THE CLIENT

I n the previous chapters, we discussed different ways to gather informa-

tion from clients. In this chapter and the one that follows, we offer guidelines about what
social workers need to do with information that indicates that a client is experiencing
abuse, neglect, suicidal feelings, or other potentially dangerous situations. While there
are differences among the various states and jurisdictions regarding the legal mandates,
we explain some universal principles that all practitioners must follow when learning
about these situations, whether during an assessment or during the course of working
with a client. We cannot emphasize enough the importance of consultation and supervi-
sion when there are concerns about a client. Supervision and consultation are important
not only at the beginning stages of a career but also throughout its entirety.

MANDATED REPORTING
Social workers, like teachers, nurses, doctors, and other professionals, are mandated to
report abuse or neglect of a child or of an adult who is over 18 years of age but considered
vulnerable due to a cognitive impairment or mental illness. The specific issues of homi-
cidal clients and social worker safety are explored in the next chapter. In this chapter, we
address the issues of protecting our clients from harm by others or self-​harm.

WHAT DOES IT MEAN TO BE A MANDATED REPORTER?

Being a mandated reported means that you are required by law to break confidentiality
in specific cases involving abuse or neglect of vulnerable people (Ainsworth, 2002).
The general language, with slight variations among each state or US territory, asserts
practitioners who have a reasonable cause to suspect that a child or vulnerable adult
known to him or her in his or her professional capacity has been or is in immediate
danger of being mentally or physically abused or neglected are required to immedi-
ately report to either the police or the appropriate protective services agency (e.g.,
child protective services, adult protective services). While there exists a variety of state
statutes on child abuse and neglect, harm of vulnerable adults, intimate partner vio-
lence (IPV), stalking, and protecting clients from self-​harm and suicide (see summary
guide for more information), there is no question that all mental health practitioners,
whether they are counselors, social workers, psychologists, psychiatrists, hotline vol-
unteers, substance abuse counselors, and others have a legal obligation to intervene
(Reamer, 2006).

WHY ARE THERE DISCREPANCIES IN REPORTING?

In spite of this legal and professional clarity, there remains great ambivalence about man-
datory reporting and a lack of adherence to the law among practitioners. Research showed
that approximately 60% of professionals do not report under mandatory reporting situa-
tions because the practitioner

• Fears disruption of the therapeutic alliance

• Does not want to be involved in legal proceedings
• Fears liability if a report is unsubstantiated
• Sees no benefit to a client
• Fears intervention may be harmful for the client
• Believes that investigation does not always strengthen families
• Feels a lack of confidence in the social and legal systems to address the issue
• Thinks they do not have enough evidence to report
• Feels they can help the client better than the “system” (Zellman & Fair, 2002)

Another reason for the discrepancies is that there is little training and educa-
tion for professionals beyond being told they are mandated reporters (Tufford,
Mishna, & Black, 2010). While extreme or obvious cases, such as serious abuse or
neglect of younger children, tend to be reported, many more cases do not. In addi-
tion, professional experience plays a role. Those with less training and those who
have never reported tend not to report. Judgments about recognition and report-
ing are not made with consistency and typically result in underreporting (Webster,
O’Toole, O’Toole, & Lucal, 2005). This underreporting becomes not only a profes-
sional training and education issue but also a supervision issue. Unlike many other
parts of our role, these situations in our professional roles are not places for critical
thinking; the law is clear about what is to be reported. It is also not the place for
criticisms of agencies responsible for handling the reports to prevent the practi-
tioner from executing this task. Protective services agencies are seen as screening
out less severe cases of abuse and often face high levels of dissatisfaction with their
performance by both professionals the community at large (Zellman & Fair, 2002).
While these criticisms may be fair, they do not relieve the practitioner of reporting
responsibilities.

74 • Moving Beyond Assessment

 LEGAL AND ETHICAL ISSUES
The social work code of ethics (COE; National Association of Social Workers [NASW],
2008) has a number of ethical standards that address the role of mandated reporter.
However, as with many ethical issues, the role of mandated reporter may make some
social workers feel that carrying out this role puts them in conflict with other aspects of
the COE. The core professional values of social justice, belief in the dignity and worth
of the person, and the importance of human relationships are particularly relevant. The
practitioner’s responsibility to clients’ self-​determination ends at the point of risk, and
the protections of confidentiality do not apply when it is necessary to prevent harm.
Therefore, we must break confidentiality when we learn that a vulnerable person is being
abused or neglected. The need to protect them outweighs the right to confidentiality. All
people deserve to be safe from harm and neglect; this protection is a social justice issue
and one that all professionals must uphold for the integrity of the profession.
A mandatory reporting situation is one in which you must have reasonable cause to
suspect that there exists an abusive or neglectful situation (Reamer, 2006). In such cases,
your role is not to be a detective and determine whether your suspicion is supported by
evidence. It is the role of an investigator to determine whether there is sufficient evidence
to support these suspicions. Your role is to report your suspicions, with support and guid-
ance from your supervisor. With the mandatory reporting responsibility comes a protec-
tion for acting in good faith under reasonable suspicion. Professionals have immunity
from civil or criminal charges that result from reporting in good faith (Reamer, 2006).
Finally, if the legal mandate to report, the ethical imperative to report, and the desire
to protect your client are not enough, know that there are clear consequences for failure
to report. These vary by state, but all include a fine, jail time, and loss of license to practice.
Someone who is a mandated reporter obviously has important responsibilities and obli-
gations. Clients should be made aware of this role at the beginning of your work together,
especially the limits of confidentiality, the intervention options, and the policies of the
agency. This process of reviewing this information with clients is referred to as obtaining
their informed consent. This term is used as you want them to have all of the information
about what they can expect so that they can be aware of their options, as well as any risks
and benefits to them, and therefore make an informed decision when they give their per-
mission to work with you and your agency. It is critical to clearly state under what circum-
stances you must report.

HOW DO I KNOW IF A CLIENT IS BEING

ABUSED OR NEGLECTED?
Many practitioners find it difficult to navigate the gray areas of what constitutes abuse
or neglect and whether what they are seeing or hearing meets that definition. Many
social workers are told that they will “know it when they see it” without being given
more training and information. Extreme cases are often obvious, but not all cases are
extreme. In these circumstances, new practitioners benefit from supervision to help

Assessing the Safety of the Client • 75

think through the details of each specific case and whether the situation rises to the
level of needing a mandatory report. In fact, we strongly recommend that all social
workers, especially those early in their careers, obtain supervision/​consultation with
a supervisor or colleague every time they suspect a client is experiencing abuse or
neglect.
While not every case presents in the same way, definitions found in the broad catego-
ries of neglect and abuse are presented next (Briere & Elliott, 2003).
Neglect entails

• Educational neglect (failing to bring children to school)

• Failure to be protected from abuse
• Lack of proper care or control by parent or caregiver
• Danger of abuse from another person in the household
• Exposure to illegal drugs

Abuse entails

• Physical harm not caused by accidental means

• Sexual abuse or attempted sexual abuse
• Mental (emotional) harm
• Sex trafficking

Given that abuse and neglect are difficult to detect in vulnerable populations, screening
for it in general populations is helpful. Research showed that children and vulnerable
adults who experience maltreatment of some form tend to have marked shifts in behavior
(a typically outgoing child is suddenly removed and shy), signs of distress and agitation
with previously neutral situations (an older adult in a nursing home begins to become
upset when the volunteer comes to take him to the park), and mental health issues such
as depression, anxiety, suicidal ideation, dissociation, and hyperarousal (Donovan &
Regehr, 2010; Lawson, 2009; Spinazzola et al., 2005). In any of these kinds of situations,
screening for maltreatment should be part of an assessment.

INTIMATE PARTNER VIOLENCE AND STALKING

There will also be information you receive in an assessment or even in ongoing work with
clients where you find that a client is being, or is in danger of being, harmed by someone
else, but the client does not meet the criteria applied to individuals for whom mandatory
reporting applies, as they are not considered vulnerable. These situations most commonly
occur in relationships in which there is physical, emotional, or sexual abuse or situations
of stalking.

76 • Moving Beyond Assessment

 ABUSE IN RELATIONSHIPS
Intimate partner violence (IPV), often called “domestic violence,” is defined as

a pattern of assaultive and coercive behaviors, including physical, sexual, and psy-
chological attacks, as well as economic coercion, that adults or adolescents use
against their intimate partners [current or former dating, married or cohabitating
relationships of heterosexuals, gay men, or lesbians]. (Tower, 2003, p. 484)

Research on IPV revealed that approximately one in four women is physically abused
by her intimate partner (Dass-​Brailsford, 2007). Prevalence rates for men are mostly
unknown, as most research is focused on women. This form of abuse can lead to death,
physical injury, and mental health issues such as depression, anxiety, post-​traumatic stress
disorder (PTSD), guilt, shame, and the risk of revictimization in other relationships
(Bennice, Resick, Mechanice, & Astin, 2003).
In addition to the direct mental health impact on the person experiencing IPV, if
there are children who witness this abuse, this experience can have negative effects on
their well-​being. Children who witness IPV may develop PTSD, dissociative symptoms,
distress, and increased aggression with peers. Witnessing IPV was found to be more
harmful to the child than being the direct victim, as their helplessness in these situa-
tions caused great distress (Antle, Barbee, Yankeelov, & Bledsoe, 2010). This finding is
even more remarkable given that approximately 70% of children who witness IPV are
also victims of physical abuse, and yet in a study the IPV was more distressing to them
(Dass-​Brailsford, 2007).
It is common for people experiencing abuse in relationships not to disclose that the
abuse is happening. For this reason and others, IPV is underdetected and undertreated by
professionals (Tower, 2003). There are several barriers to professionals properly screening
and then being able to subsequently effectively intervene with clients who present with
experiences of IPV. Some of these barriers include

• Lack of education/​training on abusive relationships

• Personal discomfort or experience with the issue
• Prejudicial attitudes toward victims “deserving it” or “provoking” their partners
• Lack of time to deal with disclosures
• Lack of institutional support to intervene (Tower, 2003)

Therefore, it is crucial that practitioners in all practice settings screen for clients who
are currently experiencing IPV, or are survivors of violence in relationships, so the clients
can be referred to the appropriate resources for support. In general, research showed that
women who should be screened are those who present with severe PTSD, have children
with PTSD, and are often isolated and lack social supports (Bennice et al., 2003). In gen-
eral, asking all clients, male and female, if they have had physical, emotional, or sexual
experiences in relationships that have felt abusive is a good place to start.
Another common challenge for practitioners is to understand the barriers that exist
for victims when they contemplate leaving an abusive relationship. It is beyond the scope

Assessing the Safety of the Client • 77

of this book to identify and explore these potential barriers, and we encourage readers
to discuss these issues with their supervisors or participate in community trainings spe-
cific to IPV. As social workers, it is not our role to “convince” a client to leave an abusive
relationship—​we must value a client’s self-​determination. We must also become educated
regarding the dynamics of power and control in abusive relationships and become famil-
iar with those that are found in the “Power and Control Wheel” (see the summary guide).
In addition, it is important not to communicate any judgments you might have about their
choices but rather to strive to understand the complexities involved in an abusive relation-
ship and help the clients to develop plans for them to remain as safe as possible given their
situation.
In working with such individuals, one tool that social workers can use with clients is
a safety plan. This tool can be used to help those in abusive relationships (and any chil-
dren involved) think through and plan for a variety of scenarios with the ultimate goal of
keeping all of the individuals in the home as safe as possible. The following are some of the
topic areas (Dass-​Brailsford, 2007) that might be discussed or addressed in a safety plan
with a client:

• How to stay safe while living with abuser

• Identifying and reviewing guidelines for leaving
• Strategies for staying safe after leaving, as this a particularly high-​r isk time

See the summary guide for links to resources for creating safety plans with clients. It is
important to check with the laws in the jurisdiction where you are practicing; in some
areas, when children are exposed to IPV, social workers are mandated to report that IPV
is occurring in the home.

STALKING
The behavior of stalking is typically understood to be a form of “obsessional following,” as
obsession is the basic element of stalking (Meloy, Davis, & Lovette, 2001). It is an abnor-
mal or long-​term pattern of behavior and interaction directed toward a specific individual
constituting nonconsensual communication with or harassment of another person (Spitz,
2003). The type of relationship between stalker and victim varies from strangers to col-
leagues, acquaintances, or prior romantic relationship partners, to name a few. Research
showed that 40–​60% of stalking victims are prior sexual intimates of the stalker, and
90% of women murdered by intimate partners were stalked prior to their death (Cox &
Speziale, 2009). If you are not sure if what a client is sharing with you meets the definition
of stalking, the most common behaviors include, but are not limited to

• Repeated following
• Repeated phone calls/​hang-​ups
• Text messages
• Unwanted gifts/​packages
• Acts of stealing/​going through mail or garbage

78 • Moving Beyond Assessment

 • Commission of breaking and entering, vandalism, theft, arson
• Incidents of stealing underwear
• Harassment of and harm to others related to victim (including pets)
• Threatening items (e.g., dead flowers, cut up photos) sent to the victim
• “Coincidental” run-​ins
• False rumors spread about the victim
• Stalking by proxy
• E-​mails/​spamming/​instant messaging
• Connections in chatrooms
• Website “tributes” or blogs
• Personal data manipulation
• Tracking computer activity
• Blackmail (Sinwelski & Vinton, 2001)

One of important roles that social workers play when working with individuals who expe-
rience any of these scenarios is to help to identify that these are potential stalking behav-
iors. It is common for victims of stalking to downplay or minimize such behaviors and not
take them as seriously as they should be. Many people minimize early signs of stalking as
signs of a “jilted lover” or those stemming from a “harmless crush” at first. It is important
to gather as much information as possible from the client and then discuss your concerns
with your supervisor. It is critical that you and your supervisor identify what message to
communicate to your client about your concerns for his or her safety.
If it does appear that the behaviors are not harmless but rather are consistent with
stalking behaviors, then we recommend that the social worker discuss the identified expe-
riences of stalking as serious and treat them as threats to the client’s safety. During this
discussion with the client, it is also important to strongly encourage and recommend to
the client that he or she cease contact with the stalker after the client has clearly stated to
the other individual to stop all communication and stalking behavior. In addition, many
practitioners who have worked in these situations state that the client should never be
alone with the stalker and to begin to build their own legal case by documenting in detail
a record of stalking episodes. It is important to

• Catalog and document all items received from the stalker

• Report all incidents to police, even if the police do not take them seriously
• Secure a new phone number and use the old one only for the stalker (keep as
evidence)
• Improve security at home, workplace, school, and all other environments
• Tell others they are being stalked and enlist their help in alerting the client to the
stalker’s attempts at contact or presence
• Develop an escape plan if you come face-​to-​face with the stalker
• Secure a restraining order when possible and safe to do so. (Spitz, 2003)

For more information about helping clients create safety plans and a stalking incident log,
see the resources in the summary guide.

Assessing the Safety of the Client • 79

SUICIDE AND SELF-​HARMING BEHAVIORS
The thought of working with someone who is actively suicidal has the potential to strike
terror in the hearts of many practitioners, particularly new ones. Part of what leads to such
a fear reaction is that these situations can be literally life or death, and we can feel power-
less to prevent the worst case scenario from occurring. Yet, to help clients who struggle
with such issues, it is important for social workers to respond proactively and learn as
much as possible about these situations, rather than to retreat in fear. In her book Night
Falls Fast: Understanding Suicide, Dr. Kay Redfield Jamison (1999) explored the history
of practitioners’ attempts to understand what causes people to want to end their lives and
how to stop them. She stated:

We have built hospitals to provide a sanctuary against madness and self-​i nflicted
death, and developed psychotherapies to ameliorate pain and to help the suicidal
navigate through the darkest times of their lives. We know a great deal about how
to prevent suicide, but not enough. And what we know, we do not use as well or
widely as we could. (p. 236)

The message to practitioners from Jamison and others who study and write about sui-
cide and its prevention is not to be afraid. It is important that we do not avoid directly
discussing suicidal thoughts, feelings, and intentions with clients due to our own fears,
discomfort, or misunderstanding about the topic. Often, we avoid discussing suicide due
to our fears that by asking about the topic, we will somehow plant this idea in a client’s
head and as a result avoid asking them if they have had thoughts of ending their life or
have had previous suicide attempts. If someone has serious and consistent thoughts about
ending his or her life, he or she will most often be honest about their history and be willing
to discuss these situations with you. As we have discussed previously, by not discussing
suicide with clients you may be inadvertently sending a message that you cannot handle
the topic or do not take their concerns seriously. There will be some people who never dis-
cuss their intentions to end their life and do so quietly and without reaching out for help.
For each of these people, there are many others who will try to get others to listen to their
desire to end the emotional pain that haunts them.
Identifying risk factors for suicide in an assessment is crucial to client care as well as to
reducing practitioner liability (Jobes, Rudd, Overholser, & Joiner, 2008). While mental
health disorders such as major depression, bipolar disorder, PTSD, borderline personal-
ity disorder, and anxiety are commonly associated with suicide, so are a family history
of suicide, major life stressors, and a prevailing sense of hopelessness about the future
(Jobes et al., 2008). Practitioners should take all expressions of a desire to end one’s life or
simply “disappear” or “not be here anymore” seriously and document all discussions and
resulting interventions (Reamer, 2005). Resources for conducting suicide assessments
and ways to intervene are listed in the summary guide.
Distinguishing suicide attempts from self-​injury is also an important part of a risk
assessment. While self-​inflicted injury is a real safety risk, it is not necessarily related to
attempts to end one’s life (Walsh, 2006). This topic was discussed in Chapter 7 on asking

80 • Moving Beyond Assessment

difficult questions, but bears repeating here. When a client has specific thoughts about
ending his or her life, has a lethal method, and has a clear plan, these indicators raise a
potential mandatory reporting situation and can frequently result in a period of hospital-
ization for the client’s own protection. Someone who uses self-​injurious behaviors, on the
other hand, to discharge emotional pain or cope with distress does not necessarily require
hospitalization but would benefit from risk-​reduction strategies and learning alternative
coping mechanisms. However, it is essential that before making such a determination of
the risk levels, social workers seek supervision or consultation with other colleagues and
document every piece of information that was used in making a decision. We provide
more information in the summary guide at the end of Chapter 7 to help navigate these
challenging situations, along with links in the summary guide in this chapter to the SAD
PERSONS scale for assessment.

IF AND WHEN YOU DO HAVE TO REPORT

If you decide after gathering information from your client and consulting with your
supervisor that you need to report that the client is in danger of harming him-​or her-
self or that others are harming the client, we recommend having all of the information
in front of you before you contact the appropriate authorities. When reporting, con-
sider asking to speak with a supervisor because you will often get a more seasoned
worker who can speak with you as a fellow professional. You will be asked to provide
your name and professional identity and role and to provide all of the known informa-
tion to establish the cause of the suspicion of abuse or neglect, including the identity of
the person(s) responsible. You will need to provide the names, addresses, phone num-
bers, physical descriptions, and any other relevant information about the individual(s)
who is at harm, as well as the individual(s) that you suspect is causing such harm. It is
important at this time not to give your opinion or speculation. As stated previously,
your job is simply to report the information that led to the suspicion; do not to pass
judgment, editorialize, or draw conclusions.
While it may seem that social workers make reports of abuse separate from their
clients, we encourage when possible to recommend to clients that they make a report
themselves or with you. While it may seem counterintuitive, making a report together
can be an empowering process, and in our own personal experiences, we have found
that it can strengthen the working alliance. When you invite and encourage your client
to be part of the process, you are reinforcing how you value the collaborative process
and the partnership you want to maintain with the client. At a minimum, discuss with
your supervisor how to tell the clients that you will be making a report. There may be
some circumstances for which you do not want to inform the client ahead of time, but
we believe that these situations are not the norm. Regardless of whether you and your
client make the report together or how much you share with the client ahead of time,
the ultimate responsibility for making the report still falls on the social worker and not
the client.

Assessing the Safety of the Client • 81

FINAL THOUGHTS ON CLIENT SAFETY
Social workers can and should feel a great deal of responsibility for the well-​being of their
clients, rightfully so. While addressing safety from self-​harm and harm by others is an
important part of our job, we must remember that we cannot “save” our clients. Clients
have the right to self-​determination and can and will make decisions that create unsafe
situations for themselves, such as remaining connected to people who we might deter-
mine are unsafe. It is extremely important that social workers do not blame the clients for
their choices but seek to understand their choices so that we can better empathize with
the complex nature of their realities. There are some behaviors and decisions that require
us to report to the authorities to protect them or their children or vulnerable adults in
their care. Other life situations will require us to help them navigate unsafe situations as
best they can. Still other situations will call on us to highlight the situations in which they
may not be safe. Balancing respect for client self-​determination while seeking to protect
them is a delicate balance to reach. As we have said throughout this chapter, we cannot
emphasize enough the importance of using supervision to help navigate these challenging
moments. It is important to consult, document, and know the laws governing your profes-
sional responsibilities where you practice. You must safeguard your professional integrity
in addition to protecting your clients.

CHAPTER 8 RESOURCE GUIDE

The following are links to reporting laws, guides, procedures, safety planning resources,
and links to assessment tools for suicide:

https://​w ww.childwelfare.gov/​topics/​systemwide/​laws-​policies/​statutes/​manda/​
Child Welfare Information Gateway: Mandatory reporting laws by state for child
abuse and neglect
https://​w ww.rainn.org/​public-​policy/​laws-​in-​your-​state
RAINN—​R ape, Abuse, and Incest National Network: Mandatory reporting laws
by state for sexual violence against children and vulnerable adults
http://​w ww.acf.hhs.gov/​sites/​default/​fi les/​f ysb/​state_​compendium.pdf
Family Violence Prevention Fund: Compendium of state statutes and policies on
domestic violence and healthcare
http://​w ww.ncadv.org
National Coalition Against Domestic Violence: Information on abusive
relationships, the power and control wheel, and guidelines for creating a safety
plan for clients in abusive intimate relationships
http://​w ww.victimsofcrime.org/​our-​programs/​stalking-​resource-​center/​help-​for-​
victims/​stalking-​safety-​planning
National Center for Victims of Crime Stalking Resource Center: Guidelines for
creating a safety plan for clients being stalked

82 • Moving Beyond Assessment

http://​w ww.suicidepreventionlifeline.org/​learn/​safety.aspx
National Suicide Prevention Lifeline: Guidelines for creating a safety plan for
clients who are suicidal

RESOURCES FOR ASSESSING SUICIDAL

INTENT IN CLIENTS
Beck Scale for Suicide Ideation: http://​w ww.beckinstitute.org/​
beck-​inventory-​and-​scales/​
Behavioral Research and Therapy Clinics: Reasons for Living Inventory and
Suicide Attempts and Non-​Suicidal Self-​Injury Scales: http://​blogs.uw.edu/​brtc/​
publications-​assessment-​instruments/​
Suicide Assessment SAD PERSONS assessment scale: http://​w ww.capefearpsych.
org/​documents/​SADPERSONS-​suiciderisk.pdf
Suicide Status Form and CAMS Approach: Jobes, D. A. (2012). The Collaborative
Assessment and Management of Suicidality (CAMS): An evolving evidence-​based
clinical approach to suicidal risk. Suicide and Life-​Threatening Behavior, 42(6),
640– ​653.

Assessing the Safety of the Client • 83

 CHAPTER 9

ASSESSING SAFETY OF OTHERS

IN RELATION TO THE CLIENT

I n Chapter 8, we addressed the importance of evaluating the client’s risk

of harm to him-​or herself. In this chapter, we emphasize the importance of being aware
of a client’s potential to harm others, including the practitioner. While the risk of being
injured on the job varies by the setting, we believe that, regardless of the environment,
all practitioners should learn to do a safety assessment of their surroundings, their own
personal safety, as well as the safety of others with whom the client may have contact. This
chapter provides general guidelines on how to conduct an environmental safety assess-
ment, with the caveat that each workplace setting will have unique conditions that must
be considered.

WORKER’S PERSONAL SAFETY

From a broad lens, violence in the workplace is defined as any action, or threat of action,
against a person in the course of carrying out their work, that creates a hostile or unsafe
work environment and negatively affects the worker, either physically or psycholog-
ically. This includes all types of physical, sexual, and verbal assaults, threats, intimida-
tion, bullying, and harassment. It also includes damage to property, stalking, and threats
to harm loved ones, including pets (Occupational Safety and Health Administration
[OSHA], 2004).
In a national study on safety in social service delivery, approximately half of those
surveyed stated that their work presented safety concerns (National Association of Social
Workers [NASW], 2006). In response to one of the questions on the survey, “Are you
faced with personal safety issues in your primary employment practice,” 44% of the
respondents said yes. In addition, 30% of those who responded to the survey did not think
that their employers adequately addressed their safety concerns. Although this study was
focused on one type of practice setting, it is important to remember that personal safety
issues are a concern in many different types of settings and should be taken seriously.
 It is likely that many social workers and other professionals do not enter situations
with clients focused on their own personal safety. Although there are individual factors
that might influence a specific person to become unsafe or violent, there are community
and systemic variables that have increased violence in places where social workers may
work. These include

• Community-​based psychiatric care for those who would have been in hospital
settings prior to the deinstitutionalization movement;
• Involvement in family disputes, including child protection and domestic violence;
• Increased financial distress and cutbacks in services and public benefits;
• Growing substance abuse issues across populations;
• Growing cultural acceptance of violence and access to guns and other
weapons; and
• Resistant or mandated clients who do not want intervention (Spencer &
Munch, 2003).

Our intention with providing this information is not to scare new practitioners, but
rather to encourage you to be a part of creating a culture of worker safety and work envi-
ronments where workers are encouraged by supervisors and agency leadership to protect
their safety while helping others. NASW (2006) reported that practitioners who encoun-
ter unsafe work situations are

• Novice workers (within the first 5 years of graduation)

• Workers in both public and private agencies serving the community
• Workers in primarily mental health and child welfare settings

In our opinion, these trends cover the gamut. Given that these trends could involve vir-
tually any relatively new social worker, we believe strongly in discussing how you can be
proactive in changing the culture of the workplace to attend to the safety needs of work-
ers. To best serve the client, practitioners need to feel safe in their work.
Most troubling for those new to the field is the research finding of an inverse rela-
tionship between worker safety and years of experience (Spencer & Munch, 2003). In
other words, the newer the worker, the higher the level of risk of being harmed by a cli-
ent. This is because most new workers do not receive safety training and do not have the
practice wisdom to know when situations are unsafe. They are more likely to worry than a
more seasoned worker about getting in trouble for not completing a meeting with a client.
While organizational leaders must attend to the task of addressing safety in the delivery
of services, there are some concrete things each practitioner can do to reduce his or her
risk of being harmed in their workplace. Social workers can deter some situations by being
attuned to signs of danger and aware that the desire to help others does not protect you
from being harmed by those you desire to help.
An important place to start for most social workers is to first acknowledge that vio-
lence can happen across all genders, classes, races, ethnicities, ages, religions, and con-
texts. We must never assume that a certain group or context is completely safe because of

Assessing Safety of Others in Relation to the Client • 85

our assumptions or biases. With this acknowledgment comes attending to our own self-​
awareness and need for vigilance. We each have our own internal “alarm system” or gut
feelings that a situation or person is not safe. Yet, we are often socialized to ignore these
signals in an effort not to rush to judgment about people and work to talk ourselves out
of our own instincts (de Becker, 1999). However, these signals are nature’s way of letting
us know when we are in danger. Therefore, it is important to pay attention to somatic sig-
nals of danger, such as a funny feeling in your stomach or the hair on your arms and neck
standing up. Fear is sometimes viewed as a weakness, but it can be a gift that can save you
from harm (de Becker, 1999).
To pay attention to your own danger cues and attend to your own safety while in the
course of your work, we suggest you think about

• Being alert to risk without being hypervigilant.

• Preparing for potentially dangerous situations with tools and knowledge of agency
policies and procedures.
• Learning to distinguish anger from rage—​W hen is a client just expressing anger
and does not have the potential to act it out?
• Identifying your subtle body cues that danger is imminent (“trip your alarm”).
• Understanding some of the reasons why people may resort to aggression.
• Examining your own personal relationship to and feelings about anger—​How do you
react when people express anger or show nonverbal signs of anger (Smith, 2006)?

DE-​E SCALATION TECHNIQUES

Some of the bullet points address being aware of your client’s emotional state. With this
awareness, it is possible that practitioners in some situations may be able to prevent a cli-
ent from escalating from anger to violence. Weinger (2001) asserted that workers can
increase their safety and reduce their risk of experiencing violence at the hands of clients
by employing techniques to de-​escalate violent behavior before it begins. She suggested
that workers should

• Appear calm, centered, and self-​assured

• Maintain a calm tone of voice as the client escalates
• Not argue with the client or become defensive
• Act respectfully at all times
• Validate client concerns while letting them know that their behavior is not
acceptable
• Not engage in an analysis of the cause of the client’s anger at this time
• Never turn their backs on an angry client or remain sitting if the client is standing
• Keep their hands where they can be seen and empty of objects
• Allow adequate physical space between them and the client
• Keep an eye on the client without appearing threatening to the client
As stated, be sure to trust your instincts. If you feel that the situation is unsafe, then there
is a strong likelihood that it is. In these situations, you can let a client know that their

86 • Moving Beyond Assessment

behavior is creating an environment in which you are both unsafe. Let the client know
that they will be choosing to end the meeting if their behavior continues. If the situation
continues to escalate, be sure to keep that boundary. If the client will not leave, you should
leave the immediate area and obtain help.

ASSESSING WORKPLACE
ENVIRONMENT SAFETY
Addressing the worker’s actions for safety is only one half of the equation. Whether
practicing in a small agency, large organization or residential setting or conducting
home visits, practitioners must attend to elements in the environment that relate to
safety. While some research showed that residential settings are more risky than oth-
ers (Winstanley & Hales, 2008), workers in all settings need to be mindful of safety
issues. NASW (2013) stated that practitioners should be in work environments that
are safe places for both workers and clients. To address these safety concerns, NASW
recommended that

• Workspaces should have visible and easily accessible exits.

• There should be alarm systems to communicate to others and obtain assistance
when the worker feels unsafe.
• Workers should be able to have another worker present when meeting with a client
who may be dangerous.
• Workspaces should be free from objects that can be used to harm others, such as
scissors, staplers, and the like.
• Buildings should have secure entry points and exits.
• Hallways, stairwells, and outdoor spaces should be well lit.
• Security cameras should be installed where appropriate.
• Mobile phones should be provided for those who work in the field.
• For workers doing field visits, risk assessments should be done prior to each visit.
• For those transporting clients in a vehicle, workers should receive specific safety
training for risk reduction, and the vehicle should be in safe working order.

In essence, the environment in which the practitioner engages clients should be thor-
oughly reviewed through a safety and risk assessment lens. Whether the setting is an
office, client residence, hospital, or residential treatment facility, the environment should
be safe to enter and stay to conduct the work of the client meeting.

RISKS RELATED TO WORK TASKS

Many practitioners face other risks related to the type of work they are doing. Working in
a domestic violence safe house, an inpatient psychiatric hospital, or a residential treatment
facility for violent offenders and removing a child from the home are just some examples
of high-​r isk activities for workers (Shields & Kiser, 2003). Working out in the community

Assessing Safety of Others in Relation to the Client • 87

or in clients’ homes is another area for consideration. Some safety tips in these situations
include the following:

• Learn all you can about the family and community before going.
• Find out about the activities and whereabouts of gangs and other groups.
• Let supervisors or colleagues know your whereabouts and times of visits.
• Touch base with them at the end of each visit.
• Dress to allow for ease of movement and ambulation.
• Avoid wearing neckties, scarves, hanging jewelry, or anything that could be used
to harm you.
• Avoid wearing religious or political symbols, sports team insignias, or anything
that could incite conflict.
• Be aware of what is posted about you on social networks.
• Drive by meeting locations to see if there are any safety concerns before getting
out of your car.
• Park in a well-​l it area, close to the entrance, and back your car into the
parking space.
• Do not leave valuables in the vehicle.
• Schedule visits during the daytime.
• Go on home visits in teams whenever possible.
• Do not enter homes where there is yelling or fighting.
• Scan the environment for weapons or dangerous pets before entering.
• Bring limited personal items with you (keys, phone, folder). Lock other items in
the trunk of your car before arriving at your parking space (Harkey, n.d.).

The importance of trusting your gut feeling and danger instincts cannot be emphasized
enough. If something does not feel right, respect that feeling and your internal alarm sys-
tem. If you become uneasy about the situation in which you find yourself, leave and call your
supervisor or the police. It is important to remember that when practitioners fear for their
own safety in the work, they are unable to be effective in the task of helping clients. Worker
safety is essential for quality and ethical client services and therefore should be a priority for
every practitioner.

ASSESSING FOR POTENTIAL

HARM TO OTHERS
Just like when a client is suicidal, when a client intends to harm someone else, there is
a legal and ethical “duty to warn” the target of the violence or contact the police (Tapp
& Payne, 2011). These situations can be challenging for all of the parties involved as the
practitioner must break confidentiality and reach out to someone in the client’s life and
warn them. Therefore, the task at hand is to weigh the level of risk and threat against con-
fidentiality and self-​determination. This task means that even the most casual statements
about a desire to harm another should be thoroughly explored. It is the practitioner’s

88 • Moving Beyond Assessment

responsibility to determine the risk level for the present situation. This determination
requires a comprehensive review of the desire, thoughts, fantasies, and wishes, as well as
any clear plans and means to carry out any plans. The more specific the plan, the more
readily available the means are available to the client, and the clearer the intent, the higher
the risk of the client carrying out his or her plan.
The first step in ascertaining if the client is thinking about harming someone else is
simply to ask. To gather this information, the practitioner should consider asking a ques-
tion that is framed in a reflection on how upset and angry the client is, linking feeling to
action, such as, “You sound very upset at Chris for how he treated you. It makes sense
to me that you are angry and hurt. Sometimes when we feel that hurt we want the other
person to feel hurt as well. Have you had thoughts of hurting Chris?” If there is a positive
response to this statement, the next step is to explore with the client further to see if there
is a plan, such as by asking direct questions like “How would you hurt Chris?” or “How
would you see this happening?”
If there appears to be a plan, the next step is to determine whether the client has access
to the means to carry out this plan and how likely the client would be to carry out the
plan. To gather this information, practitioners can ask a question such as “You stated that
you would like to see Chris feel your pain so much so that you’d hit him with a baseball
bat. How likely are you to carry this out?” Practitioners can explore this subject further
by asking the client if there are any reasons why he or she would not do this. What would
prevent or hold him or her back from carrying out this plan? We also believe it is useful
to explore what might happen if he or she went through with this action and if he or she
can identify any negative consequences to him-​or herself. If the client cannot identify
any risk, practitioners can explore with the client if he or she could anticipate any legal or
social ramifications or how hurting the other person would help your client alleviate his
or her own emotional pain.
If the risk of your client harming someone else is low, you can validate the feelings
while helping the client find alternative coping mechanisms to harming others. If the
risk is midrange (the client cannot say for sure that he or she would not do it), then
it is crucial to consult with a supervisor or colleague to review the level of risk and
your decision-​m aking process. Finally, if the risk is determined to be high, you should
intervene immediately, as this is where your duty to warn comes in. For new practi-
tioners, this intervention should be done under the guidance and direction of your
supervisor or their designee. Attempts should be made to reach the intended victim
by phone, e-​m ail, and any other means. When speaking with the intended victim,
only information related to the threat may be shared. No other confidential client
information should be given to the intended victim. If the person cannot be reached,
then employ the assistance of the police. A police report should also be made at this
time (Jongsma, 2004).
As a guiding principle, every interaction with a client and your actions pertaining to
a client should be documented in the client’s chart. It is even more important to docu-
ment every conversation and attempt to explore a client’s homicidal ideation or intent.
In the records, we recommend that practitioners provide any client quotes and any cli-
ent statements that pertain to the reasons for not carrying out the actions. In addition, it
is important to provide detailed descriptions of any consultation sought in the case and

Assessing Safety of Others in Relation to the Client • 89

follow-​up conducted. Finally, be sure to document the interventions taken or when and if
the homicidal ideation or intent ceases.

FINAL THOUGHTS ON SAFETY

Thinking about clients harming us or someone else is not comfortable, but it is essen-
tial to ethical practice. As with many uncomfortable tasks, it can be easy to be in a place
of denial or avoidance of these tasks. As more workers require their practice settings to
address the health and safety of the staff, it will not be incumbent on the practitioners to
raise these issues themselves. However, in all work situations, to fully assess the health
and well-​being of our clients, we must explore our own safety and the safety of others in
relation to the client. If we choose to neglect this task, we not only are being unethical, but
also are putting ourselves and others into dangerous situations that could be avoided if we
take a proactive stance.

CHAPTER 9 RESOURCE GUIDE: WORKER

SAFETY PLAN AND CHECKLIST
WORKER SAFETY PLAN
According to OSHA (2004), there are five core elements to a safety plan for mental health
practitioners. This should form the basic framework of any safety plan developed at your
place of practice. They are as follows:

1. Management-​/​leadership-​driven efforts with employee involvement—​Th is should

include a zero-​tolerance policy for verbal or physical abuse, threats of violence,
and bullying behavior. This should be communicated to all staff and clients.
2. Worksite analysis—​A thorough inspection and analysis of physical workspaces
should be undertaken to assess for potential threats to safety. This analysis
should include a thorough review of previous incidents of violence, as well as
identification of high-​r isk settings and clients. Workers who conduct home vis-
its or work in residential settings should be given specific safety training for
these settings.
3. Prevention—​Actions should be taken to remediate any of the threats to safety
identified in Step 2 and any course of action necessary to reduce risk of harm
to workers. Common steps include installing alarm systems, “panic” buttons in
consulting rooms, and adequate lighting outside the building for workers who
leave at night.
4. Safety training—​Safety training and risk reduction skills seminars should be pro-
vided for all staff, student interns, and volunteers, regardless of their service

90 • Moving Beyond Assessment

 provision role. This training is crucial for setting the issue as a priority for the
agency. Supervisor training is also essential, as their response to a worker who
feels unsafe or experiences violence can make a significant difference.
5. Record-​k eeping and evaluation of the efforts—​Tracking incidents of violence or
threats against workers is an essential part of worker safety. Each practitioner
should know how to report these incidents and be aware of what happens to
these reports. Debriefing of incidents with all staff is an important part of this
process as well. In addition, ongoing evaluation of the effectiveness of worker
safety programs will be helpful to make future improvements.

For more information about developing a safety plan at your program, visit https://​w ww.
osha.gov/​SLTC/​healthcarefacilities/​v iolence.html.

CHECKLIST
For each individual practitioner, it can be difficult to determine when they are not safe
with a client or are just feeling anxious or absorbing some projections or transference
from the client. This checklist can be helpful to determine when you may not be safe.
Remember that you should screen for safety risks with all clients, but pay specific atten-
tion to your safety with the client who

➢ Has a history of violence

➢ Has perpetrated violence against an intimate partner or child
➢ Has an active substance abuse problem
➢ Has a recent history of explosive anger
➢ Has a history of conduct disorder or antisocial personality disorder
➢ Appears agitated and difficult to calm
➢ Appears disoriented and dissociative
➢ Has made threats against you or workers in your organization
➢ Has access to weapons
➢ Has a history of psychosis and noncompliance with medications

Assessing Safety of Others in Relation to the Client • 91

 PART I I

PLANNING AND
IMPLEMENTING
INTERVENTIONS
 CHAPTER 10

EVIDENCE-​BASED PRACTICE
AND HOW TO USE RESEARCH
IN TREATMENT PLANNING

T here are many aspiring social workers who enter their graduate p­ rograms
paralyzed by fear at the thought of research. Words such as statistics, probability, and
­significance levels make their heads spin as they drudgingly head into their required research
courses. As a result of this attitude, on completion of these courses, many master’s of social
work (MSW) students as well as those from other disciplines breathe a sigh of relief as they
tell themselves they will never again have to think about research. However, the reality is
that in today’s world of practice, no clinician should or can practice without considering
research in the clinical decision-​making process.
In actuality, many social workers really do care about research; they just do not know it.
They care about research because they care about finding out which is the best intervention
for their clients’ unique needs and circumstances. They care about making sure that what
they are doing with their clients is working effectively toward achieving the goals of the
intervention. For example, if you find yourself asking any of the following questions, you
care about research:

• What is the best way to help my client?

• How will I know if what I am doing is working?
• What is the latest information on a particular disorder, mental illness, or
health issue?
• What have other agencies or communities done to effectively address a particular
issue on a macro level?
• What have other clinicians done previously to address a problem? Did it work? How
so? If not, why not?

Our guess is that most of you ask yourselves at least one of these questions. More import-
ant, our profession believes that such questions are important. The National Association of
Social Workers (NASW) Code of Ethics states that “social workers should base practice on
recognized knowledge, including empirically based knowledge, relevant to social work and
social work ethics” (NASW, 2008, 4.01.c).
This chapter’s aim is to help new professional social workers see that research is not
only critical to good practice but also does not have to be confusing and scary and there-
fore avoided. When we avoid understanding and utilizing research, we risk not offering the
best available treatments for their clients. Finally, according to our own professional code of
ethics, by not including research findings in our intervention decision-​making process, we
are not following the values of the profession or being ethically responsible as professionals
(NASW, 2008).

RESEARCH AND SOCIAL WORK: WHAT DO

YOU NEED TO KNOW?
While there are many different ways that clinicians can use research in social work, here
we introduce one main approach, evidence-​based practice or EBP. EBP is a process of using
information that includes the clinician’s expertise, the client’s wishes and circumstances,
and the best available empirical research, while considering the contextual factors, in
the clinical decision-​making process (Drisko & Grady, 2012). Each of these factors is
important to consider when attempting to develop a potential intervention that you will
cocreate with a client. EBP in social work is derived from and is related to evidence-​based
medicine (EBM) in the medical field. A widely cited definition of EBM in clinical prac-
tice was offered by Sackett, Rosenberg, Muir Gray, Haynes, and Richardson (1996):

Evidence based medicine is the conscientious, explicit, and judicious use of cur-
rent best evidence in making decisions about the care of individual patients. The
practice of evidence based medicine means integrating individual clinical exper-
tise with the best available external clinical evidence from systematic research.
(pp. 71–​72)

This definition has been expanded to include the clinical circumstances relevant to the
client, which is more consistent with social work. Such circumstances might include the
financial status, the work schedule, child-​care requirements, or transportation barriers for
the individual. As such, the model that we use in this book has four parts: (a) the current
clinical circumstances of the client, (b) the best relevant research evidence, (c) the client’s
values and preferences, and (d) the clinical expertise of the professional clinician (Haynes,
Devereaux, & Guyatt, 2002).

EVIDENCE-​BASED PRACTICE
You might be asking, “So, what does EBP mean exactly?” or “What does this look like
in practice?” What EBP emphasizes is that social workers need to follow a process of

96 • Moving Beyond Assessment

decision-​making that ensures that all four of the areas mentioned are included. The idea
is that if all four areas are considered, the worker and the client will be using a plan that
is based on a holistic view of the client and one that is based on empirical support for its
effectiveness.
As stated previously, EBP is a process. While the steps may vary slightly, the overall for-
mat is generally the same. The steps of the EBP decision-​making process are as follows:

1. Draw on client needs and circumstances learned in a thorough assessment, identify

answerable practice questions and related research information needs;
2. Efficiently locate relevant research knowledge;
3. Critically appraise the quality and applicability of this knowledge to the client’s
needs and situation;
4. Discuss the research results with the client to determine how likely effective options
fit with the client’s values and goals;
5. Synthesize the client’s clinical needs and circumstances with the relevant research,
develop a shared plan of intervention collaboratively with the client;
6. Implement the intervention (Drisko & Grady, 2012, p. 32).

A brief vignette follows to further illustrate this process. Please note that these are
selected excerpts of a case, and that only segments particularly relevant to the process
are shared here. Other areas of concern to social workers have not been shared, such
as information about housing and socioeconomic issues, and the client’s numerous
strengths are not discussed at length. All of this client’s identifying information has been
changed.

Alice is 24-​year-​old who identified as a biracial, heterosexual, and agnostic woman. She came
to a community mental health center at the recommendation of her primary care physician,
who had performed a complete physical and could not find any medical explanation for her
symptoms. She reported a number of gastrointestinal symptoms that included cramping,
frequent bowel movements, and stomachaches. She had lost weight over the last 3 months.
The social worker completed a thorough bio-​psycho-​social-​spiritual history and asked ques-
tions about her strengths and the start of the symptoms, their severity, and their duration. An
important part of her history that emerged in the assessment was that her parents separated
when she was only 2 years old. Her mother was Caucasian, and her father, with whom she did
not have a close relationship, was from Ethiopia. Her father had intermittent contact with her
over the years, but she remained with her mother and felt that her stepfather was much “more
of a real father” than her biological father ever was. Her father’s family was a very close-​knit
family that remained insulated and close to other Ethiopian families in the area. She did not
feel connected to them and felt anxious when she needed to spend time with them because she
did not understand most of what they said and did not understand or participate in many of
the cultural activities. She stated that she “always feels on the outside.”

Step 1—​A ssessment: You need to learn strong clinical skills so that you are able to con-
duct a thorough assessment and identify clearly what it is your client is seeking in treatment
(Grady & Drisko, 2014). It is important not only to identify what you think would be most

Evidence-Based Practice and How to Use Research • 97

helpful but also to remember to learn from the client what he or she believes would be help-
ful to address in your work together. Based on the assessment, you need to develop a good
question from which to launch your decision-​making process that is specific to the needs of
the client. Examples of potential questions that social workers might ask in their work with
clients (not necessarily the case of Alice) could include the following:

• How can attachment be improved in a recently adopted child?

• What are effective interventions for older women who are depressed?
• Is family therapy or individual therapy more effective in helping adolescents with
substance abuse issues?
• Are some interventions focused on addressing anxiety more effective than others
depending on the racial or ethnic identity of the client?
• What does a typical grieving process look like for children?

In Alice’s case, the symptoms began after her biological father announced that he was going to
be married in the summer and expected her to be in the wedding. He was marrying another
Ethiopian woman from their community, and Alice was overwhelmed at the thought of being
there and having to participate with “a bunch of people I do not know doing things I do not
understand.” In addition, she was picturing her father “acting like we are all one big happy
family, which is FAR from the truth, and I am going to have to pretend like we are!” Her stress
over this event appeared to have brought on the symptoms, and she was physically uncomfort-
able and had also missed work due to the physical symptoms. She stated that at the moment
her boss was tolerant of her missed days to a point, but she really could not take more sick days.
In the conversations with Alice, the social worker and Alice determined that a searchable ques-
tion in this case would be “What are effective treatments for managing anxiety that manifest
as physical symptoms?”

Step 2—​Search: In Step 2, you need to be able to locate relevant research that will help
you to answer the question you developed in Step 1. This is when you need to use the web-​
searching skills you learned through graduate school and in your library orientations. If you
are not familiar with how to search databases to find information, this would be a good time
to meet with your local librarian, either in your community or at your university. If you do
not have access to academic search engines that are available through most universities, a
suggested list of publicly available resources that you can use to search for potentially rele-
vant information is in the Resources section of this chapter.

A quick search on the Cochrane Library (http://​www.cochrane.org) for anxiety treat-

ments with physical symptoms resulted in several hits. The top one was for a review called
“Improving Return to Work in Adults Suffering From Symptoms of Distress.” This systematic
review addressed 10 studies focused on this issue. In this case, five of the studies used cognitive
behavioral therapy and five used problem-​solving therapy. Based on their review,

98 • Moving Beyond Assessment

 Our results showed that workers on sick leave because of an adjustment disorder can be
helped with making their first step back to work (i.e. partial return to work) by treating
them with problem solving therapy. On average, workers who are offered problem solv-
ing therapy start 17 days earlier with partial return to work compared to workers who
receive no treatment or the usual treatment from their occupational physician or gen-
eral practitioner. However, we also found that cognitive behavioural therapy or problem
solving therapy does not help the worker return to work with full-​time hours any quicker
than workers who receive no treatment or the usual treatment from their occupational
physicians or general practitioners. (Arends et al., 2012, para. 1)

The authors noted that more research is needed on this topic to better understand what is
helpful to this population.

Step 3—​Evaluate: Now that you have gathered some information, this step involves
using the knowledge that you gained in your research courses to critically evaluate
and appraise what you have found. Some of the questions you might be considering
include whether a finding is statistically significant or if the sample that the researchers
included in their study was similar to the client(s) with whom you are working. There
will be many studies that are complicated and present information on statistics that
you may not understand. While you will certainly not catch everything in the article,
be a critical thinker while reading. For example, were the instruments used valid and
reliable? Did the authors provide you enough information on the research process in
general? Does the project even make sense to you? Is it clear from the article how to
replicate the study or the intervention? In Appendix B is a guide developed by Bruce
Thyer (1991) to help individuals use critical thinking skills while evaluating a research
article.

The Cochrane Library is known for strong systematic reviews. The benefit of a systematic
review is that the researchers have searched and evaluated the information for the reader.
In addition, given that this review was done fairly recently (within the last year), the social
worker felt confidence in these conclusions.

Step 4—​Collaborate: The important piece to remember in this step is the need to have
a conversation with your client about what you have learned, rather than simply reporting
what you found to your client. This conversation should be a dialogue that involves dis-
cussing the information with your client. It is important to clearly state what you found, as
well as what your thoughts are about what you found. Also important is to keep in mind
that you will need to tailor the information based on language, cognitive capacity, and
other relevant considerations particular to the specific needs and characteristics of your
client. This step occurs when you and your client come to some mutual understanding
about what makes the most sense in terms of an approach to address the need identified
in Step 1.

Evidence-Based Practice and How to Use Research • 99

 After finding this information, the social worker discussed these results with Alice. Together,
they explored what problem-​solving therapy was, whether this form of intervention made
sense to the client in terms of her understanding of both the origins and potential resolution
of the issue, and whether this form of intervention felt realistic to her. They also discussed the
findings concerning cognitive behavioral therapy and reviewed similar information together.
Alice believed that the problem-​solving approach fit well because, although she had had
anxiety-​related symptoms in relation to her father in the past, she felt like this event was the
main issue and felt like the approach would target that. This approach felt like a better fit
for her.

Step 5—​Plan: Building on the conversation in Step 4, your job in Step 5 is to synthesize
all of the information into a coherent plan considering all of the components included in
EBP: client factors (i.e., wishes, interests, capacities); clinician factors (i.e., expertise, skills);
research factors (i.e., what the literature reports might be effective); and contextual factors
(i.e., culture, family context). Your expertise is involved in every prior step, from clinical
skills in the assessment and in discussing information with the client to technical skills of
being able to effectively search databases. In Step 5, though, your job is to bring all of this
information together and to develop an appropriate plan that takes into account the conver-
sation you had in Step 4.

The social worker now used the previous discussion with Alice in which Alice expressed her
wishes and thoughts, in combination with the social worker’s knowledge of both problem-​
solving therapy and cognitive behavioral therapy paired with the research, to create an inter-
vention plan to move forward with problem-​solving therapy. Here, the social worker needed to
consider what Alice’s wishes and preferences were, what the research said might be useful, and
her own expertise, including her expertise that was outside what the research identified. In this
case, the worker was in fact trained in the models that were identified by the research, and the
client felt that such an approach, specifically the problem-​solving approach, was a good fit for
her, so no outside referral was needed. If, however, the social worker did not have that expertise
or the client expressed a different wish, the outcome could have been different. For example,
if the social worker in this case did not have any expertise in this model, it would have been
appropriate for the social worker to have shared that information with the client and offered
either to provide her with possible referral options or to state what she could offer and what
empirical support, if any, she knew of regarding such an approach.
In this case, they created a contract for 3 months with the overarching goal to increase
Alice’s coping capacities to effectively manage the stress and anxiety surrounding her father’s
wedding. These capacities would include a range of interventions in keeping with the approach,
including defining the problem and generating alterative solutions and skills, such as relax-
ation techniques and visualization and self-​monitoring.

Step 6—​Implement: After the process has been completed, it is now time to launch the
plan. Depending on the client population or the agency where you work, the plans for each
client may be very similar or very different.

100 • Moving Beyond Assessment

 Alice began to work immediately with the social worker using problem-​solving therapy and
began to address the concerns she had on entering the clinic.

Although not included here, one additional step that is often included in the EBP pro-
cess is the evaluation of the intervention. Social workers need to develop ways to assess
whether what they are doing is working and be responsive when it is not. Because evaluating
one’s own practice is so important, we have dedicated a chapter to this process, Chapter 15.

LIMITATIONS OF EBP
EBP is meant to be a critical thinking process that encourages social workers to think broadly
about how to approach different issues in social work. However, there are a number of lim-
itations that should also be considered. Drisko and Grady (2012) provided a thorough sum-
mary of these limitations, and those interested in reading more on this topic are encouraged to
refer to this source. However, the main limitations that they identified are summarized next.

SO C I AL JUST I C E C ONC ERNS

Much of the research conducted on social problems is focused on resolving individual func-
tioning rather than structural issues. Many feel that this focus is

at odds with some of the core values of social work. These include inadequately
addressing structural issues that may contribute to social justice concerns and
further pushing social work toward a limited medical model orientation rather
than promoting biopsychosocial and interdisciplinary models. (Drisko & Grady,
2012, p. 242)

In other words, by studying interventions focused on individual functioning, the implica-

tion is that the cause of the problems originates from the individual, rather than contextual
factors, such as poverty, crime, violence, and racism, to name a few.

L IMI TAT I ONS OF THE RESEARCH

One of the limitations most often cited regarding EBP is the lack of research regarding a
host of issues (Drisko & Grady, 2012). These include demographic characteristics, diagnos-
tic profiles, as well as contextual issues such as research on alleviating poverty or reducing
rates of community violence. For example, if you had a female client who recently immi-
grated from Ghana, experienced high rates of community violence, was a sexual abuse sur-
vivor, and was now pregnant and suffering from pregnancy-​related depression, it would
be difficult to find a study that included research subjects who fit her exact description.
Therefore, practitioners must think about the most relevant question related to her specific
needs at that time, as well as which demographic characteristics are most salient regarding

Evidence-Based Practice and How to Use Research • 101

her treatment. EBP argues for the use of the best available research. Therefore, social work-
ers must use what they can find and then incorporate that information in to the other three
factors considered in EBP. The field, however, is limited by what is available.

REAL I T I ES OF REAL-​W ORLD PRACT I C E

Another critique of EBP that clinicians have noted is that often the empirically supported
interventions that are identified in the EBP process do not “take into account the ‘messi-
ness’ of real life practice” (Drisko & Grady, 2012, p. 243). Clients and their lives are com-
plicated, and like the client example presented in the preceding section, they face multiple
issues. It is unrealistic that there will be a perfect fit between an intervention approach and
the clients’ needs. As stated previously, it is in these complex cases that practitioners must
use their expertise to prioritize the needs of their clients and work with them to identify the
intervention that is the best fit when possible.

OVEREMPHAS I S ON THE RESEARCH

There have been some in the field who believe that EBP ignores the expertise of the prac-
titioner, relying too heavily on the research, and ignores the art of social work practice
(Drisko & Grady, 2012). We hope that it has been clear throughout this chapter that the
social worker’s expertise is critical through the entire EBP process. The critique mainly is
concerning the fear that practitioners will simply search for an intervention and then imple-
ment it without really considering the client wishes, the importance of the relationship with
the client, or the art of doing social work (Graybeal, 2014). We believe strongly that even
models with the strongest level of empirical support must be provided in the context of a
strong working alliance, as we discuss in Chapter 2.

LOG I ST I C S OF EBP
Another critique surrounds the logistics of completing the EBP process. It requires practi-
tioners to have access to some research databases (although there are many publicly avail-
able) and relies on practitioners having some ability and confidence to interpret research
findings. In addition, agency budget limitations exist that may prohibit a worker from
receiving training in and supervision for implementing a new intervention. Finally, there
may be a lack of community resources for any identified interventions.

CONCLUSION
In spite of the limitations of EBP, it provides a critical thinking process that infuses research
into a client-​centered approach to practice. We emphasized in this chapter the essential role
research plays in our profession and in our work with clients. It is vital that social workers be

102 • Moving Beyond Assessment

able to articulate why they are doing what they are doing. The EBP process provides social
workers with a concise method for answering such a question by allowing them to articulate
their practice decisions in a manner that is consistent with both the person-​in-​environment
approach used by social workers and with the code of ethics that addresses professional eth-
ical behavior.

APPENDIX A: RESOURCES
This appendix is a list of resources available that are free to the public. For a more com-
prehensive discussion of the different available resources, refer to Chapter 5 in Drisko and
Grady (2012), from which this list has been derived and modified.

• The Cochrane Library. This is a database of very high-​quality systematic reviews

(syntheses of available research) on single topics. The Cochrane Library is organized
by disorder and medical model in orientation: http://​www.cochrane.org
• The National Guideline Clearinghouse. This is a compilation of treatment guidelines
derived by expert panels but based on research results. It is organized by disorder
and medical model in orientation: http://​www.guideline.gov
• The Centre for Reviews and Dissemination databases at the University of York includes
the Database of Abstracts of Reviews of Effects (DARE). DARE compiles over 15,000
systematic reviews, including those of the Cochrane Collaboration discussed
previously: http://​www.crd.york.ac.uk/​crdweb/​
• The Centre for Evidence-​Based Medicine provides summaries from the Cochrane
Database and weekly updates of new additions and changes to the Cochrane
Database (which include many new titles at the beginning stages of research as well
as newly completed systematic reviews): http://​www.cebm.net/​
• The UK National Health Service’s Clinical Knowledge Summaries provide a source
of evidence-​based information about common conditions for the primary care
practitioner. They include both medical and mental health disorders: https://​www.
nice.org.uk/​about/​what-​we-​do/​evidence-​services/​clinical-​knowledge-​summaries
• The National Mental Health Information Center of the US Substance Abuse
and Mental Health Services Administration (SAMHSA) offers “kits” to
translate evidence-​based programs into practice: http://​store.samhsa.gov/​list/​
series?name=Evidence-​Based-​Practices-​KITs
• The National Registry of Evidence-​Based Programs and Practices, which is part of SAMHSA.
It is an online searchable database of over 250 programs: http://​www.nrepp.samhsa.gov/​
• The National Implementation Research Network. This website contains a series of
briefs focused on children and on implementation lessons learned from an initiative
in North Carolina to study whether postcare supportive services improved the long-​
term well-​being of children exiting foster care: http://​nirn.fpg.unc.edu/​
• The Center for Evidence-​Based Practice (CEBP) at Case Western Reserve University.
The CEBP provides technical assistance—​consulting, training, and evaluation—​for
service innovations that improve quality of life and other outcomes for people with

Evidence-Based Practice and How to Use Research • 103

 mental illness or co-​occurring mental illness and substance use disorders: http://​
www.centerforebp.case.edu/​

APPENDIX B: GUIDELINES FOR CRITICAL

ANALYSIS OF RESEARCH ARTICLES

TITLE
1. Does the title include accurate identification of problem area, variables specified, and identifi-
cation of target population?

INTRODUCTION
1. Did the report appropriately cite earlier, relevant studies drawn from the social
work and other disciplinary literatures?
2. Was the research problem or question clearly stated?
3. Did the introduction conclude with one or more explicitly stated testable
hypotheses?

LITERATURE REVIEW
1. Was adequate and relevant literature cited to acquaint the reader with the existing
studies that had been found?
2. Was adequate and relevant literature cited to establish the need for the study and
the likelihood of obtaining meaningful, relevant, and significant results?
3. Were the variables included in the study adequately supported for use with relevant
literature?
4. Did the author(s) offer clear definitions of key terms and variables?
5. Were operational definitions used whenever possible?

METHODS

SAMPL ING
1. Was a clear, potentially replicable description provided of the sampling procedure
used to recruit clients for the study?

104 • Moving Beyond Assessment

2. Were the criteria for inclusion and exclusion of subjects clearly stated?
3. Were salient characteristics (demographic, clinical, diagnostic, etc.) of the sample
of clients described in detail to permit comparisons of this sample with those
used in prior (and future) studies?
4. Was a description of the nature of the informed consent process used to obtain
client agreement to participate in the study provided?

INDEPENDENT AND DEPENDENT VARI ABLES

1. Were the independent and dependent variables conceptually defined in an under-
standable manner?
2. Did the operationalization of the variables follow the conceptualization?
3. Did the instruments used in the study possess acceptable levels of reliability and
validity?
4. Were the instruments clearly pertinent to the target problem?
5. Was the choice of instrument(s) supported by relevant literature?

INTERVENT I ON (IF APPL I CABLE)

1. Was the intervention program (treatment) described in sufficient detail to permit
replication? If not, did the author provide a source to obtain a treatment manual
or more explicit description of the intervention(s)?
2. Were measures taken to assess practitioner compliance with intended interven-
tions? If so, were the interventions carried out as intended?
3. If blind conditions were imposed on clients or practitioners (or both), were mea-
sures taken to assess the integrity of the blind nature of the study participants?

RESEARCH DES I GN
1. Did the authors provide a clear description of the research design employed?
2. If clients were assigned to various conditions, was the nature of this assignment
process described in sufficient detail to permit replication?
3. If random assignment was employed, was the nature of the randomization process
clearly described?
4. Were pretreatment measures taken of the clients’ problems? If so, were the groups
of clients assigned to differing experimental conditions roughly equivalent to
each other pretreatment?

DATA C OLLECT I ON AND ANALYS I S PLAN

1. Was it clear how the data was collected (where, when, how, and by whom) and
recorded?

Evidence-Based Practice and How to Use Research • 105

 2. Was there enough information on the data collection to allow for replication?
3. Was the plan for analysis clearly presented?

RESULTS
1. Were the results obtained from the various measures consistent with one another?
Was the pattern of improvement (or deterioration) clear across all measures?
2. Were the results presented in the form of graphs or tables? Is so, were the data com-
prehensible without recourse to the narrative text.
3. If the results were reported in the form of descriptive statistics, was each mean
accompanied by a standard deviation?
4. If inferential statistics were employed, were the data shown to meet the assump-
tions the tests were based on (e.g., normal distribution, similar standard
deviations, etc.)?
5. Did the level of measurement for the instruments used fit with the statistical tested
used to analyze the data?
6. If correlational measures were employed, are the N, correlation coefficient, and
alpha level reported for each such analysis?
7. If a t test or analysis of variance was used, did the report of each such test contain
the degrees of freedom, t or F value, and alpha level?
8. If a statistically significant result was found, was the proportion of variance explained
by this difference reported?
9. Apart from statistically significant changes, was the clinical significance of any
improvements discussed?

DISCUSSION
1. Did the author clearly address alternative explanations (e.g., threats to internal
validity) for the results, apart from the hypotheses that were tested?
2. Did the author report only conclusions supported by the data? Were speculations
clearly described as such, rather than as facts?
3. Were the limitations of the study clearly stated?
4. Were suggestions to improve future research in this area described?
5. Were clear applications to practice derived from this study described, with special
reference made to the unique aspects of social work practice?

Taken from “Guidelines for Evaluating Outcome Studies on Social Work Practice,” B. A.
Thyer, 1991, Research on Social Work Practice, 1(1), 76–​91; Handbook in Research and
Evaluation, S. Isaac & W. B. Michael, 1971, Educational and Industrial Testing Services, San
Diego, CA.

106 • Moving Beyond Assessment

 CHAPTER 11

ROLE OF THEORY IN SOCIAL

WORK PRACTICE

I n Chapter 10, we discussed the evidence-​based practice (EBP) process that

integrates the client’s preferences, the best available research, and the practitioner’s exper-
tise into the decision regarding an intervention for a client (Drisko & Grady, 2012). There
are several critical areas for practitioner expertise: the ability to form relationships; knowl-
edge of the population and the context of practice; and knowledge of and comfort level
with different models of treatment. Another crucial area of expertise is in knowledge of dif-
ferent explanatory and practice theories that strongly influence the assessment and change
processes. Therefore, new social workers must be aware of the important role theory has in
social work practice and begin to strengthen their knowledge of and ability to apply both
explanatory and change theories in their practices.
In this chapter, we hope to accomplish three primary goals. The first is to clarify and
define terms related to theory that social workers will encounter in the field. The second
is to explain the important role theory has both in the assessment phase and in planning
for and implementing any intervention with clients. Our final goal is to help social workers
strategize ways to gain more expertise in using theory to assess and inform interventions.

CLARIFYING TERMINOLOGY
Often, what creates confusion for professionals is how terms are frequently used inter-
changeably and often inappropriately. The terms theory, model, and intervention are often
confused by social workers yet have very different definitions. While the terms are related,
they each play a distinct role in social work and should be understood as separate concepts.

THEORY
According to Walsh (2013), there are several types of theories used by social workers. “Case
theories explain the behavior of one person (for example, an individual spouse abuser”
(p. 3). It is common for social workers to develop their own theories about why their clients
do what they do. A second type of theory according to Walsh is a midrange theory, which
aims to explain “a set of cases or events” (p. 3). An example might be trying to understand
the reasons for one community’s spike in reports of violent crimes. Finally, Walsh identified
grand theories that “attempt to explain all sets of events and cases (such as Freud’s theory of
psychosexual development or Piaget’s theory of cognitive development)” (p. 3).
These theories as outlined by Walsh all represent explanatory theories that are designed to
help us to understand and then explain to others the existence of phenomena. Social workers
are often asked to explain why a client might have symptoms of depression, why a particular
community is experiencing a higher rate of criminal behavior, why the morale within an orga-
nization has dropped significantly, or why family members have chosen not to speak to each
other. Each of these questions requires a social worker to look at a complex picture and try to
distill it down to an understandable explanation to which clients can relate.
In addition to explanatory theories, social workers use theories of change, sometimes
referred to as practice theories (Walsh, 2013). These theories do exactly what they sound
like they do: They provide a theory regarding how change might occur. Frank and Frank
defined a practice theory as “a coherent set of ideas about human nature, including concepts
of health, illness, normalcy, and deviance, which provide verifiable or established explana-
tions for behavior and rationales for intervention” (as cited by Walsh, 2013, p. 3). These
theories help to predict how change might occur or how to help to facilitate change. Rather
than explain why a phenomenon exists, they serve to help us predict how a phenomenon
might be altered.
All of the theories currently used by social workers were developed by someone who
wanted to better understand why certain phenomena existed and how those phenomena
could be altered in some way. Before a theory can be considered viable, it needs to be tested
and evaluated for validity (Hutchinson, 2013). In other words, has there been research on
whether the theory is accurate? Some theories are easier to test than others.
Let us take an example of an agency director who has noticed that residents from a par-
ticular neighborhood in the agency’s catchment area do not come for services. She develops
an explanatory theory that the reason these residents of that community do not come to the
agency is because they do not have access to transportation. Using this theory, she develops
a theory of change aimed at increasing participation by these residents and determines that
the agency should provide buses to the neighborhood to help those individuals come to the
agency. However, before moving ahead to work on an action plan to develop transportation
services for this community, it is in the director’s best interest to first test the theory by going
out and asking the residents why they do not use the services of the agency. She finds that
there is a perception in the community that the agency is biased against those individuals
who live in the community, and this perception is the reason that community members do
not come to the agency for help. This testing of the explanatory theory yielded a different pic-
ture of what was causing the phenomenon compared to the director’s initial theory. Had the
agency director moved ahead with her own theory, the agency would have spent a great deal
of money on resources that would not have addressed the issue she was seeing at the agency.
Another example that is perhaps more complex is trying to understand why sexual
assault occurs in our communities. There are many explanatory theories regarding why
individuals commit sexual assaults, yet there is no one theory that appears to sufficiently

108 • Moving Beyond Assessment

explain this behavior among the different individuals who commit such heinous crimes
(Grady, 2009). With sexual assault, there is no one theory that fits all. As such, it is dif-
ficult to develop theories of change that could then have an impact on the number of
sexual assaults committed.
Although it is likely that the theories you learn in social work school have been tested
and validated, it is important to evaluate the validity of the theories you learn and to place a
value on the importance of testing your own ideas that you have developed about what you
are seeing in your own practice settings. Social workers need to be cognizant of how their
own assumptions and biases can influence their assessments with clients.

MODEL
Change theories are ideas about what might help to facilitate the intended outcome
(Walsh, 2013). These ideas are then operationalized into models that help to frame how
the change should occur. Models take the ideas regarding what might work and spell out
how to create a desired change—​step by step. For example, the Wright brothers first had
an idea about how to fly before they could build a model of an airplane that they could
test. In social work, models are used to operationalize an intervention approach. The
model includes specific information about who meets with the social worker, what the
social worker does with the clients, what kinds of questions the social worker asks, how
often the social workers and clients meet, and more. Each practice model, regardless
of the level of clients system for which it is designed, will provide guidance for how to
organize and implement the intervention.
Some of the practice models that you learn in graduate school might include models
of interventions designed to reduce depression, organize community members, or reduce
violence in schools. Each of these models is based on explanatory theories, which led to
theories of change, which were then operationalized into a model that provided a set of
guidelines and steps to reach the desired outcome. For them to be considered empirically
supported interventions (ESIs) model, they need to have met certain criteria to demon-
strate that they are superior in reaching those outcomes compared to other approaches (see
Chapter 10 on EBP and Drisko & Grady, 2012). While other models may be promising or
perceived as helpful, a model can only be referred to as an ESI when it has met those stan-
dards. Throughout your careers, you will consistently need to evaluate different interven-
tion models, their fit with your population, the needs of your client, as well as the research
that has been used to test whether it is effective in creating change. (For a much more thor-
ough discussion of how social workers can evaluate research as well as infuse research into
their practices, see Drisko & Grady, 2012.)

INTERVENT I ONS
The term intervention is confusing because it actually does hold different meanings. As we
have already mentioned in this chapter, we have used it to talk about working with clients to

Role of Theory in Social Work Practice • 109

create change. We are intervening or creating an intervention that is the overarching action
we are taking with clients to reach an outcome. Within the intervention, we may use a par-
ticular model to help us facilitate that change.
Yet, the term intervention is also used to describe the specific tasks, strategies, or tech-
niques taken within a model. A task might be to teach new skills or to provide psycho-
education to a client. When referred to as a stand-​alone task, they are not considered an
all-​encompassing model of intervention. Rather, they are a discrete action that is taken
within the intervention phase of the relationship with a client or clients. Each model will
often prescribe a set of tasks that is consistent with the theory of change. Walsh (2013)
defined intervention strategies as the “concrete actions taken by social workers to help cli-
ents achieve their goals” (p. 4).
Let us say, for example, you have met with a client who is struggling with depression.
There are numerous theories that might explain this struggle. One theory that a social worker
could use is cognitive theory (CT). As an explanatory theory, CT states that the reason peo-
ple feel depressed is because they have thoughts that lead them to feel sad. According to
the theory, our thoughts influence how we perceive ourselves and our world (Beck, 2011).
Building on this explanation, according to CT, the theory of change is that if we can change
our thoughts and how we perceive ourselves and the world, we will feel better. In the cogni-
tive model of change, the clients and practitioners meet for 12–​14 sessions that are divided
by phases; each session is structured in a particular format; and the practitioner takes on a
particular role with the clients, often like a teacher, and teaches the clients new skills to alter
the thoughts. Therefore, the specific interventions or tasks within the model are skills used to
address thinking patterns to challenge or alter the thoughts that are leading to the depression.
As you can see from this example, the explanatory theory, the theory of change, the
practice model, and the specific intervention strategies are all interconnected and build on
each other, creating a logical sequence starting from the explanatory theory to the specific
intervention strategies used to address the client’s depression. According to Walsh (2013),
“There should be consistency … between a practitioner’s working theory and interven-
tions” (p. 4). Without such consistency both you and your clients can become confused
about why you are doing what you are doing. The explanation for the issue should clearly
link to what you and your client think you should do about it.

USE OF THEORIES IN SOCIAL

WORK PRACTICE
The act of using theory to explain a phenomenon requires knowledge and several key skills.
To start, social workers must have working knowledge of a range of theories that they can
use to understand issues that affect different levels of client systems (micro, mezzo, and
macro). Working knowledge means that they can define and explain the assumptions and
key concepts of a theory.
Once there is some solid understanding of the theories, it is important for social workers
to be able to apply these theories to complex situations. Understanding the ideas of a theory
is different from being able to apply the knowledge. What we mean by this last statement is

110 • Moving Beyond Assessment

that being able to define the terms or concepts of a theory is a source of knowledge that is
distinct from the skill of being able to use the theory to explain an issue. In other words, can
you use the theory to explain what is going on with a client or client system? For example, if
a family came in for help with their 10-​year-​old son, who was getting in fights at school, what
theories could you use to help explain that behavior both for yourself and for the clients?
Would you use an individual theory, such as CT as described previously, to explain how the
thoughts or perceptions the son had about his peers led him to believe that they will hurt
him if he does not show he is tough? Or, would you use a family theory to explain that, in
his family for multiple generations, his family members have used violence as a way of man-
aging uncomfortable emotions? There is no right or wrong answer as both theories help to
explain the same phenomenon.
The task for the social worker is to identify which theory might be most relevant and
then apply the concepts of the theory to explain the case. It is also important then to trans-
late the language of the theory so that it is useful in understanding why the phenomenon
is occurring and finally to link that explanation to the plan for action along with the EBP
process. In our experience, students find that understanding the theory and its concepts is
much easier than applying the knowledge to their cases and work in the field. It takes prac-
tice and a skill we encourage all readers to practice in their classes and in the field with the
clients with whom they are working.

LINKING IT ALL TOGETHER

We hope you can see by now, theories play a critical role in helping to explain human beha-
vior and social phenomena as well as planning for action. Without valid and reliable theo-
ries, social workers would simply be trying and using a smattering of ideas without having
a cohesive or organized way to approach their work. We also hope that it is clear that we
believe strongly that there should be a clear link between the explanation of the issue and
how to intervene. For example, say you went to your doctor for help with your heel, which
has been hurting. Your doctor explains the reason you have the pain is because you have
been exercising in shoes that provide no support, and your heel has been strained as a result.
You think, “OK, that makes sense. My shoes are really old, and my foot always hurts after
I exercise.” Now, imagine the doctor says to you, “So, the way to address this heel pain is for
you to eat more apples.” Of course, that makes no sense! The plan for intervention should
match the explanation regarding the cause of the issue. A much more logical intervention
plan based on the explanatory theory would be to be fitted for more supportive shoes and
try to include lower-​impact exercise in your routine to take the pressure off your heel. The
explanation should connect to the plan.
Figure 11.1 is a visual depiction of how theories connect to the intervention process.
Figure 11.1 represents the general flow of how to link your explanation to your intervention
strategies.
In our experience, students and new practitioners are most anxious to know the inter-
vention strategies. They want to know “what to do” in their work. Our response is typically,
“Well, it depends on your goals, which were based on your assessment, which was driven by

Role of Theory in Social Work Practice • 111

 Explanatory Theory of Model of Assessment Goals for Intervention
Theory Change Practice of Issues Intervention Strategies

FIGURE 11.1: Connection between theory and intervention.

your model of practice, which was based on your theory of change, which was influenced
by your explanatory theory.” There are many intervention strategies that are used across
different models of practice. However, why you are using it and your ability to explain that
reason is connected to the explanatory theory. It is not enough just to offer clients new skills
or ideas. Which ones, why those, and why now are all driven by your assessment of the issue
that is grounded in the explanation.

HOW TO PICK A THEORY

If you are in school or recently graduated, you have probably discovered that you can choose
from numerous social work theories. There are individual, family, group, organizational, and
macro theories, all of which are useful in helping to understand clients and client systems
in different ways. The summary guide at the end of this chapter provides a brief outline of
some of the major theories that social workers use. It can be overwhelming for new social
workers to think about learning all of the potential theories and to learn them well so that
they can be applied competently to their practices.
Of course, there is no way that any one social worker can master them all. Therefore, in
our teaching and supervision of social work students and practitioners, we use the following
guidelines to help prioritize your learning:

• Become familiar with at least one theory for each level of social work practice: micro,
mezzo, and macro.
• Even if you think that you will always be a direct practitioner, macro and social
issues influence your clients, and you must have an ability to frame larger social
context issues for yourself and your clients.
• If you are going to focus your work in one particular level of practice, you will
want to learn more of those relevant theories.

112 • Moving Beyond Assessment

 • For direct practitioners specifically, learn at least one skill-​based theory and model,
one relational-​based theory and model, and one family theory and model. You can
then draw on what you need having these tools in your toolbox.
• Skill-​based theories and models are important because sometimes clients need
concrete help in tackling a particular issue, especially if it is acute.
• Relational theories and models are important because they teach you how and
remind you to attend the client relationship, which research continues to show is
a critical part of any form of intervention (Hubble, Duncan, Miller, & Wampold,
2010; Norcross, 2002; Wampold, 2010).
• Family theories and models are important because they help social workers to
consider systemic and multigenerational patterns that influence developmental
and current patterns. Even when working individually, family theories help
remind us of these influences and help us to understand their role in the current
struggles faced by our clients.

Over your career, you will be introduced to multiple models of practice. We encourage
you to identify ones that are most relevant to your work and to try to learn them well.
“While knowledge of multiple theories may be unnecessary, it is nevertheless essential
for effective psychotherapists to understand at least one theory well in order to apply it”
(MacDonald & Webb, 2006, p. 3). Although MacDonald and Webb were writing about
psychotherapists specifically, their ideas apply to other levels of social work practice. They
also stated:

Limited understanding of even one theory relegates psychotherapists to adding a

method here and an idea there, without a systematic conceptual basis to hold those
methods and ideas together; this is conceptual syncretism. In the worst cases, psycho-
therapists operate out of syncretism, wherein they unsuccessfully attempt to synthe-
size different, perhaps contradictory, ideas and methods, with little or no awareness
of their inherent incongruities. A cogent conceptual system, though, would solve this
difficulty. (p. 3)

Unfortunately, in our own careers, we have seen many practitioners, social workers as
well as others from different disciplines, practice in a way that is consistent with syncretism,
and these individuals are unable to article which theories they use and why. Given the mul-
tiple theories that are available, paired with the complex needs of our clients, it is easy to see
why many practitioners have turned to what is often referred to as an eclectic or integrated
approach (MacDonald & Webb, 2006; Prochaska & Norcross, 1999; Walsh, 2013). In fact,
over several decades, practitioners were asked about their approach to working with clients,
and over one third of the respondents identified eclecticism as their primary approach; this
was the largest category chosen (Norcross, Hedges, & Castle, 2002). In a similar study con-
ducted by Jensen, Bergin, and Greaves, 59% (psychiatrists) to 70% (clinical psychologists)
of the groups sampled regarded themselves as eclectic (as cited by MacDonald & Webb,
2006). It is clear from these studies that many practitioners draw from multiple theories and
models rather than just one. However, MacDonald and Webb cautioned that “such a strat-
egy … is no solution for syncretism; indeed, it may increase the risk of syncretism” (p. 5).

Role of Theory in Social Work Practice • 113

 To reduce the risk of syncretism, we advocate for an intentional or purposeful inte-
gration of theories rather than a haphazard hodgepodge of ideas that are thrown together
at random. It is important for practitioners to be clear about which theories (explanatory
and change) they are using and why they are using those theories and to be competent in
applying them. Many models currently used combine different theoretical concepts into
a new approach (e.g., mindfulness-​based cognitive therapy; Segal, Williams, & Teasdale,
2012). Research consistently demonstrated that the competency of the practitioner to use
theory effectively is a critical component of a successful intervention (Wampold, 2010).
“Conceptual clarity is essential, though, if psychotherapy is to fulfill its claim and potential
to provide scientifically based services” (MacDonald & Webb, 2006, p. 5). If, for example,
an intervention approach with a client does not appear to be effective in helping the cli-
ent to reach his or her goal, without a cohesive and coherent approach it would be impos-
sible to know whether it was the approach itself, the lack of competence in carrying out
the approach, the combination of ideas that have been mixed together, the absence of the
parts of an approach that were dropped, or some other variable. Understanding outcomes is
complex. However, by providing clients with a cohesive and well-​thought-​out approach will
help to determine what is working and what is not.
All of this information about theories leads us to advocate for being intentional in what
theories or models of practice you use and potentially combine. Think carefully about why
you feel compelled to integrate different approaches and how the different theories will
complement or potentially contradict each other. Plan for how you will explain these com-
bined theories to your client and how they will ultimately connect to your intervention
plan. If you feel that you need to use more than one theory to either understand or plan for
change, then we encourage you to use an approach that uses “informed eclecticism” (Goin,
2005, p. 255) rather than one that resembles syncretism. Be clear about what you are doing
and why so that you can articulate your approach to others. In hiring social workers for an
agency in a previous capacity, I (E.D.) would ask each applicant: “What theories or models
of practice guide your interventions with clients?” Applicants who could not answer that
question in a thoughtful and coherent manner were not considered for the position.

WHAT ABOUT EVIDENCE-​B ASED PRACTICE?

In Chapter 10, we discussed EBP and its role in planning for interventions. Theory and
EBP go hand in hand, but one should not trump the other. As you can see from Figure 11.1,
your assessment of the issue is driven by your explanatory theory. It is important to be cog-
nizant about which theory you tend to rely on, as this will ultimately shape how you view
client issues and what you then identify as a searchable question in the EBP process. Your
expertise on different theories and practice models will play a role in what you can offer to
your clients as well.
At the same time, we worry about practitioners being drawn to the idea that they can
do an EBP search that will identify a specific model of practice that they can just “do”
with their clients without linking that intervention plan to an explanatory theory: They
just get a manual and off they go. Social work is more complex than finding a manual for

114 • Moving Beyond Assessment

a standardized treatment and fitting clients into that box. As we discussed in Chapter 10,
there are several limitations regarding EBP. One of these is that there is a paucity of
research that will match perfectly with your clients and their needs. It is in these circum-
stances that your knowledge of theory is even more important. You will need to turn to
your theories to help guide you when there is no relevant empirical research that might
help you plan for your intervention.
The other way that theory and EBP compliment each other is when a standardized
model of practice needs to be modified in some way. As previously stated, clients are com-
plex, and they may need to have intervention plans modified to align more consistently with
their cognitive, diagnostic, family, or social context needs. Your knowledge of social work
theories will help to guide you regarding when and how to modify models of practice that
you identify during the EBP process to best meet the needs of your clients.

SOME WORDS OF CAUTION

While we hope we have made a strong case for social workers to use theories in their work
with clients, we also want to note some cautions in the use of theories. One of these is that
theories are by nature reductionistic. One of the main benefits of theories is to reduce a
great deal of information to a format that can be understood. One image that helps illustrate
this point is the optical illusion that looks like a mess of colors and lines when you first look
at it. However, once you put on special glasses (which are often colored and look funny),
the image becomes clear, and the picture embedded in the mess of colors and lines stands
out. This is the benefit of a theory; it is the lens through which you view a client’s situation
to provide clarity, understanding, and direction.
On the flip side, any theory limits the information that you use as you attempt to
reduce the information to digestible portions. For example, let us return to the previous
situation of the client who was depressed and how we were using CT to understand the
depression. By focusing on the client’s cognitions or thoughts, we have a clear theory
of causation and a clear plan for intervention. However, by focusing on the thoughts,
we miss the underlying poverty, racism, and community violence that are also contrib-
uting to the depression and may be the reason the person has negative thoughts about
herself. When using CT, we become less interested in where these thoughts originate
than in understanding their influence in the life of the client and providing new skills to
alter those thoughts. The theory provides a clear path from explanation to intervention.
However, it is important to remember that the path is formed by the theory’s assump-
tions about what is important in understanding human behavior. When we choose one
theory, we are therefore making a choice not to include others that could lead us down
different paths with clients. The existence of multiple paths is why it is important to
know multiple theories. If the theoretical path you are on leads you and the client to a
dead end, you can choose another path.
Another caution is that once you learn and master a theory, you can become depen-
dent on this theory and this theory alone. We have each had colleagues who were experts
in applying a theory in their work but could not switch their perspective. They had their

Role of Theory in Social Work Practice • 115

hammer, and everything else became a nail. So, while it is important to become competent
in your theories, also remember that there are other ways to look at any one situation. The
EBP process is a way to help remind us of the multiple factors that should be considered
when thinking through how to work with any one client or client system.
It is also important as you learn different theories to think about why you are drawn to
one theory but not to another. As we have stated previously, throughout your careers you
will be exposed to multiple theories and practice models. Note which ones you embrace
and which ones you reject. Be curious and critical about this process, as you may learn
something about yourself during it. Just because you like it does not mean that it is a valid
or reliable theory. Be cautious to embrace a theory without examining it thoroughly with a
critical eye.
To that end, Hutchinson (2013) developed a set of criteria to use when learning a the-
ory as a way to evaluate its usefulness in social work:

• Coherence and Conceptual Clarity: Are the concepts clearly defined and
consistently used? Is the theory free of logical inconsistencies? Is it stated in the
simplest possible way, without oversimplifying?
• Testability and Empirical Support: Can the concepts and propositions be
expressed in language that makes them observable and accessible to corroboration
or refutation by persons other than the theoretician? Is there evidence of empirical
support for the theory?
• Comprehensiveness: Does the theory include multiple dimensions of
persons, environment, and time? What is included, and what is excluded? What
dimension(s) is (are) emphasized? Does the theory account for things that other
theories have overlooked or been unable to account for?
• Diversity and Power: Can the theory help us understand uniqueness and
diversity? How inclusive is it? Does it avoid pathologizing? Does it address power
arrangements and systems of oppression? Can it be used to promote social justice?
• Usefulness for Social Work Practice: Does the theory assist in the
understanding of person-​and-​environment transactions over time? Can
principles of action be derived? At what levels of practice can the theory be used?
Can the theory be used in practice in a way that is consistent with the NASW
Code of Ethics? (p. 30)

These criteria can be helpful to review as you think about what the strengths and limitations
of each theory are as well as how they fit with your own assumptions about human behavior
and, most important, the clients with whom you will be working throughout your careers.

CONCLUSION
Social work theory is critical for understanding and intervening with a range of issues
faced by clients and the communities in which we live. While there are limitations to

116 • Moving Beyond Assessment

their utility, they provide structure and guidance in working in complex situations, espe-
cially when there is little empirical information on which to draw. While it is tempting
to integrate ideas from multiple theories to help address the complexities of practice,
social workers should be intentional in their blending of theories to ensure that their
approach remains purposeful and cohesive. We strive to be versatile in our use of theory
in an effort to prevent becoming stuck in one way of working that is likely not to be ben-
eficial for all clients. Theory provides social workers with the language to articulate to
clients and others why we are doing this particular act with this particular client at this
particular time.

Role of Theory in Social Work Practice • 117

CHAPTER 11 RESOURCE GUIDE
This chart provides a brief overview of some of the major theories social workers use in practice.

Influential
Theorists/
Name of Theory Theory Focus Explanatory Concepts Intervention Concepts Specific Techniques Used Clinicians
Psychodynamic How internal •  The mind consists of an •  Change comes through •  Attention to Sigmund Freud
Theories (with and external unconscious and conscious. provision of a “secure base” affects, emotions, Anna Freud
attention to forces interact •  Defense mechanisms protect for relationships to develop, and developmental Hartmann
Attachment to shape and humans from anxiety and leading to a corrective processes Erikson
Theory) influence unacceptable impulses. emotional experience. •  Empathy Klein
emotional •  Humans adapt to their •  SW [social workers] and •  Clarification Mahler
development environment. others must be careful not •  Exploration Winnicott
and social •  Humans have inborn needs to to reenact past negative •  Education Kohut
functioning attach to others and internalize relationship patterns. •  Support of adaptive Bowlby
relational experiences, forming •  Through increasing functioning Ainsworth
views of self and others. recognition of interpersonal •  Interpretation
•  Infant–caregiver relationships patterns and understanding •  Provision of a secure,
set developmental trajectories, of the origins of these holding environment
influencing how the past persists patterns, clients are able to for client to explore
into the present. consciously make different experiences, thoughts,
•  Humans need a responsive choices, develop more positive feelings, relationships
environment to develop a sense of relationships, and have •  Use of therapeutic
trust in the world, but when early increased functioning. relationship as
developmental needs are not met, reflective of client’s
individuals develop unhealthy experience
patterns of functioning and
relating.
Behavior Theory Seeks to •  Cognitive: Activating •  Cognitive: Therapists help •  Cognitive Bandura
and Cognitive understand how Event-Belief-Consequences: individuals to recognize restructuring Pavlov
Theory (with overt behaviors •  The person’s thoughts their unhelpful thought techniques: e.g., Skinner
attention to (actions) influence their feelings and patterns and teach new Socratic questions; Watson
Cognitive and covert behaviors. skills to challenge and alter evidence for & Albert Ellis
Behavioral behaviors •  Unhelpful thoughts create those thoughts so that the evidence against Aaron Beck
Practice (thoughts or unhelpful consequences. subsequent consequences will •  Cognitive coping: e.g. Judith Beck
Theory) emotions) can •  Behavioral: Antecedents- be different. “I” statements, coping
be understood Behavior-Consequences: •  Behavior: Change is focused cards
through •  Respondent: pairing two on either altering the •  Exposure therapy
examining stimuli together will create an antecedents (respondent or systematic
unhelpful association. conditioning) or the desensitization
thinking and/ •  Operant: the consequences consequences (operant) or a (based on classical
or behavioral following a behavior will behavior. conditioning)
patterns that either increase or decrease •  CBT [cognitive behavioral •  Operant conditioning
have been the likelihood of the behavior therapy] is a practice model with positive
learned over continuing. that combines both into one or negative
time •  Social Learning intervention approach with reinforcements, such
Theory: Modeling the assumption that thoughts, as Reward charts
•  Behavior is learned through behaviors, and emotions are •  Mindfulness—
individual experiences. all connected, and changes in connecting mind and
•  Behavior is maintained one of those domains changes body
through its antecedents and the others. •  Increasing emotional
consequences. vocabulary
(continued)
 Influential
Theorists/
Name of Theory Theory Focus Explanatory Concepts Intervention Concepts Specific Techniques Used Clinicians
General How persons •  Persons are in continual •  Behavior is related to •  Attention to Durkheim
Systems interact transaction with their structure of one’s family interconnections Parsons
Theory (with with their environment. system, and problems in between person and Weber
attention environment; •  Systems are interrelated parts functioning stem from the environment Merton
to Family how the family or subsystems constituting an problematic family structures. •  Use of ecomaps Bertalanffy
Emotional & system affects ordered whole. •  Changing one part of the and genograms to Germain
Structural functioning •  Each subsystem impacts all other system (e.g., the family understand system Gitterman
Family across the life parts and the whole system. system) can have an effect on dynamics Bowen
Systems span •  Systems can have closed or open the system as a whole. •  Focus on improving Minuchin
Theories) boundaries. •  Targeting the whole system verbal and nonverbal
•  Systems tend toward equilibrium. can address issues of any one communication among
•  Individual functioning shapes individual. subsystems
family functioning, and family •  By changing the system, each •  Assessment of family
functioning can create pathology individual may function better. development and life-
within the individual. •  Change occurs by taking in cycle transitions
•  Boundaries regulate the flow energy/information/resource •  Use of family and
of inputs (energy, information, and then expelling energy/ parent coaching
resources) entering and leaving information/products that are •  Use of joining
the system. different from the inputs. techniques,
•  Open dynamic systems are disequilibrium
both self-maintaining and techniques, and
self-transforming. psychoeducation
Organizational How individuals •  Groups are open, dynamic •  The structure of organizations •  Explain and map the Weber
Theories (with and groups in systems with both change and influences the success of staff direction and role of Taylor
attention to organizations conflict present. and the outcomes for clients. collective action Mayo
Contingency gain power, •  Groups are stratified, with •  There is no one best way •  Assess power blocks Bertalanffy
Theory) access to different and unequal levels of to manage organizations; it •  Build individual and Lawrence
resources, and power and control. depends on the nature of the community strengths Lorsch
control over •  Oppression occurs when upward environment. •  Support upward March
their lives, mobility is systematically denied. •  Organizations and the social mobility of oppressed
often through context must be critiqued and groups
collective deconstructed. •  Assess the fit
action •  Assessment of internal between internal and
and external resources external resources;
leads to structural and stated and real goals
process decisions within
organizations.
•  There needs to be a good “fit”
between internal organization
features and environmental
demands.
(continued)
 Influential
Theorists/
Name of Theory Theory Focus Explanatory Concepts Intervention Concepts Specific Techniques Used Clinicians
Conflict/Critical How power •  All societies perpetuate some •  Understanding conflict •  Attend to evidence Marx
Theory (with structures forms of oppression, injustice, and between persons, ideas, of oppression within Manniheim
attention to and power structural inequity. groups, classes, and larger individuals, groups, Lukacs
Empowerment disparities •  Power is the ability to influence social structures is useful and communities Marcuse
Theory) impact people’s the course of one’s life. for macro-level practice and •  Attend to the role of Mills
lives, both •  Power is unequally divided, and policy analysis. conflict leading to Dahrendorf
individually and some groups inevitably dominate •  Formulating assessments client vulnerability Freire
as a society others. of client vulnerability and •  Recognize the Solomon
•  Social order is based on oppression may lead to client dominant and Gutierrez
manipulation and control by organization and an increased subordinate groups Rose
dominant groups. sense of power. that compete for
•  Social change is driven by •  Increasing personal, resources
conflict, with periods of change interpersonal, or political •  Focus on individual
interrupting periods of stability. power enables individuals, self-efficacy and
•  Life is characterized by conflict, families, and communities consciousness-raising
not consensus. to take action to achieve •  Empower oppressed
•  Structural barriers prevent personal and collective goals. and vulnerable
people from accessing resources populations by
necessary for health and well- organizing to alter
being and reaching full potential. power relationships

Used with permission from Susanne Bennett, PhD, associate professor at the Catholic University’s National Catholic School of Social Service.
 CHAPTER 12

THE MIDDLE PHASE

OF TREATMENT

T he middle phase of treatment is often the one that students and new clini-
cians are most eager to learn and often remains the most challenging part of working with
clients. It is the part where students say, “OK. I have figured out how to form a relationship
with my clients. I have gathered all sorts of information about their struggles, challenges, as
well as their strengths and protective factors. This chapter addresses the phase that comes
next with clients. It is often referred to as the middle phase of practice because it comes
after the assessment and before the termination or ending phase. However, in reality, these
three phases often blend into each other because the minute you meet your client, the work
begins. In addition, in the very first session there should be a conversation about the end,
often referred to as termination, which is then referenced during the entirety of the work
with clients. Therefore, while this chapter addresses a middle phase of the work, your “inter-
vention phase” with clients begins as soon as they make contact with you or your agency.

THE INFLUENCES OF THEORIES

AND MODELS ON THE MIDDLE PHASE
The type or the specifics of the work that takes place during this phase of intervention
greatly depend on the explanatory and change theories used (see Chapter 11) as well as the
distinct model of practice that has been chosen during the evidence-​based practice (EBP)
process (see Chapter 10) and treatment-​planning processes (see Chapter 13). The types
of tasks that are described in the treatment plan are generally created based on the chosen
approach to addressing the problem. For example, if the client and social worker have cho-
sen to use cognitive behavioral therapy (CBT; Beck, 2011) to address the issues, then the
tasks and focus of the intervention will be on addressing cognitive and behavioral patterns.
If the client and social worker have chosen a family therapy approach, such as Structural
Family Therapy (Walsh, 2013), then the focus in the intervention phase will be on address-
ing role and communication patterns within the family, among others. If the chosen form
of intervention is the use of case management (Greene et al., 2006), then the focus will be
to increase social supports based on patterns of isolation or social needs. A final example
is if the client and social worker have chosen to use a relational approach, such as Child-​
Parent Relationship Therapy (Bratton, Landreth, Kellam, & Blackard, 2006), then focus is
on interpersonal or relational patterns.
In all of these scenarios the key word is patterns. Regardless of the type of intervention
that a social worker in partnership with a client chooses to take, the focus is on recogniz-
ing the patterns that are creating the distress or contributing to the presenting issue. Based
on these patterns, practitioners then offer new skills, experiences, or resources to disrupt
or alter the unhelpful patterns to create new, more adaptive or helpful patterns. The social
workers role, then, regardless of the model of intervention, is to help clients recognize how
these patterns contribute to their current struggles, to link the pattern to the presenting con-
cern, and then to help the client to develop new patterns.
The explanatory theory that you have chosen to use is a critical tool during this process.
It is helpful for clients to understand how these thinking patterns or relational patterns are
connected to their current struggles. The explanation provided by the social worker helps
clients to make the link between the why and the “what next.” The what next or the interven-
tion will then involve asking clients to do things differently, which can be scary. Yet, there
are many paths to take, and an open and collaborative approach with clients will help ensure
that they are engaged in and understand the chosen plan. The pathway that is chosen for
these tasks will vary depending on the selected intervention approach.
It is beyond the scope of this book to describe every approach to addressing patterns.
There are some excellent resources provided in the summary guide to help social workers
dive more deeply into the particulars of the different approaches. Books that offer chap-
ters on different models of intervention are wonderful resources to understand how various
approaches help you execute the intervention phase. However, in this chapter, we provide
some commonly used tools that can help social workers in this middle phase of intervention
to begin pattern recognition and alteration.
We find it useful to organize this phase of treatment into four main steps. We encourage
our students to be explicit and transparent with their clients, as we are with our own clients,
about these steps so that the clients themselves are aware of the process and can be partners
in it. Different change approaches will emphasize some of these steps more than others, yet
in our experience of studying, teaching, and using different models of intervention, they all
adhere to this general structure.

1. Identify the patterns

2. Link the patterns to the presenting problem/​issue/​concern
3. Explain how the pattern may have developed and its purpose
4. Develop new patterns

We believe that these steps capture the essence of the intervention phase of working with
clients in practice.

124 • Moving Beyond Assessment

1. PATTERN IDENTIFICATION
As stated previously, the first phase of the intervention process is to identify the problematic
patterns. What is challenging about this phase is that the clients may not be aware of the
patterns that are creating their distress, may not be interested in addressing these patterns as
they may be mandated clients, or may be aware of patterns that are challenges for them but
may not recognize the role they play in their distress. It is therefore important for the social
worker to help clients identify patterns using a client-​friendly and nonthreatening method.
In this chapter, we cover two main formats for identifying patterns: charts and journaling.
Different models may use other methods or slight variations of the two that we present here.
These examples give you an overview and understanding of the main methods for gathering
the information you are seeking.

CHARTS
The most common way of identifying patterns is to chart them. Charts are used in multiple
formats and can be easily individualized to help clients identify different information about
the patterns. The main information that is captured in a chart includes

• When the pattern occurs (e.g., time of day, location, with certain people, under what
circumstances), which helps to identify specific triggers;
• What occurs within the pattern (e.g., descriptions of thoughts, emotions,
physiological responses, behaviors);
• How often the pattern occurs (e.g., daily, weekly, hourly counts);
• Intensity of the experiences identified in the “what” step (e.g., defined on a
standardized scale or a 0–​10 well-​defined scale); and
• Duration or how long the pattern lasts (could be within a day or over longer periods
of time).

The information regarding the pattern that is captured on the chart could be tracking any-
thing from internal experiences, such as a mood or physical sensation, to external experi-
ences, such as getting into a fight or losing a job. What you are trying to elicit will often be
led by the theory you are using to guide your practice (i.e., behaviors, thoughts, relationship
patterns, communication, symptoms).
There are multiple benefits to charting patterns, including

• Identifying triggers (i.e., people, places, things)

• Increasing self-​awareness
• Empowering client to have a role in the process
• Conveying the value of the client’s knowledge and insights about the problem
• Organizing complex information
• Creating a format to focus the targeted information being sought

The Middle Phase of Treatment • 125

While there are many benefits, it is important to recognize that while charting can seem
easy on the surface, it can be difficult for clients to complete for many reasons, including
the following:

• Disorganization (i.e., losing the paper or forgetting to write information down)

• Embarrassment about what it reveals about their thoughts or behaviors
• Lack of motivation (i.e., they may see the issues as others’ fault; however, those can
also be charted)
• Challenges due to learning disabilities, cognitive disabilities, or reading and writing
limitations
• Lack of resources or proper environment (i.e., no writing supplies, living space that
does not provide privacy or space to think)
• Fear (i.e., concerns about others around them accessing the information)
• Fear of placing a burden on others (e.g., a teacher who is being asked to track the
details of multiple behaviors of a student in a class of 30 others)
• A feeling that charting is too much like homework for those who have had negative
academic experiences
• Need for time to capture information
• Lack of a chart at the time of the event
• A burdensome feeling to the client or whomever is completing the chart

Due to these reasons, it is imperative that social workers and the clients work together to
develop a realistic charting system that will work for them. It may seem that there are more
costs to charting than benefits. However, in our experiences, the benefits often outweigh the
costs, and we have also found that many of the concerns about charting can be managed or
addressed in open discussions about why they are used and what benefits the client can expect
from their work.
The structure of the chart can be whatever the social worker and the client feel captures
the information in a useful way. Most of the time, the information that is being sought is
placed across the top of the sheet with a separate column for each piece of information; each
individual event that is tracked is on the left-​hand side of the paper. Please see Tables 12.1
and 12.2 for examples of charts.

TABLE 12.1: Chart Example 1

Date/​Time Event Thoughts Feelings Behaviors

126 • Moving Beyond Assessment

TABLE 12.2: Chart Example 2

Date/​Time Event Behavior Intensity Duration

JOURNAL ING
Journaling is another method often used to capture information, and for some clients it is
the preferred method. Rather than dissecting each aspect of any pattern, journaling allows
clients’ entries to be less formatted and more descriptive about their patterns in their own
voice and style. Some clients prefer a more open approach to capturing their experiences,
and journaling allows them to express their experiences in a narrative form.
Journaling can take many forms, but generally it simply involves clients writing in a book
or on a pad of paper about what they notice, attempting to record the same information that
a chart would capture. The information sought is the same. Only the format used to capture
the information is different. Clients can then write about their experiences in whatever for-
mat they find to be most useful in describing their experiences of the pattern. Some of the
benefits include the following:

• There is flexibility in describing information.

• It can be less confusing than figuring out what information goes where on a chart.
• Additional information may be captured beyond the standard information (i.e., their
own insights or “aha moments”).
• It encourages self-​reflection.
• Clients are empowered to find their own “voice” through their writing.
• Writing is another medium for those who are not verbal processors to express
their ideas.

However, as with charting, there are downsides to journaling. Many of these are the same
as for charting. In addition to those already listed, journaling can raise anxiety levels in some
clients as they struggle to capture their thoughts in what they perceive is a “right way.” They
may worry about what you will think when you read the journal or fear it being found and read
by others. For many clients who struggle with spelling or writing, journaling may feel burden-
some and intimidating. Therefore, as with all tasks suggested to clients, it is important to assess
your clients’ willingness, motivation, and capacity to carry out any task asked of them.
For clients who struggle with writing or have other challenges with written expression,
there are several other options that they can use to capture the same information that might
be captured in a chart or in a journal. One option is for them to use pictures. These pic-
tures can be drawings or stickers. Another option is for the practitioner to provide the client
with a premade chart that has either pictures or words that might capture an experience or
feeling. Instead of writing out the experience, the client can circle already-​printed words

The Middle Phase of Treatment • 127

on a chart or other form. In addition, many clients now have smartphones that have apps
for tracking a wide variety of information, including feelings and behaviors. Practitioners
can work with clients to identify free apps that are helpful in tallying whatever informa-
tion might be useful in their process. One final option, also using a smartphone, is to make
an audio recording, with the client verbally describing the information you are trying to
capture. This option may be helpful for individuals with learning disabilities or for younger
children who struggle to translate thoughts into written words.
Regardless of the format used to record the information about the pattern, the main
goal of this first step is to help you and your client identify in detail the patterns with which
the client is struggling. Once this information has been captured, it is much easier for you
to help your client connect those patterns to the presenting problem or concern for which
they are seeking some support.

2. LINKING THE PATTERN TO

THE PRESENTING CONCERN
Now that you have helped the client identify the patterns, the next step is to link this pattern
to their presenting problem. This step in the process and the following one are both linked
closely to your use of an explanatory theory. What we mean is that here your job is to help
your clients understand how the patterns that they have identified are no longer helpful to
them although they may have been during different phases of their lives (we expand this
point in Step 3). Your explanatory theory is the key to helping them to make this connection.
For example, imagine you are working with a 25-​year-​old woman named Jackie who has
been attempting to secure employment. However, each time she gets to the interview stage
that her vocational counselor has arranged, she is rejected immediately after the interview.
Her vocational counselor feels qualified to help her connect to positions that are a good fit
based on her job skills, but the social worker does not feel qualified to help her address some
of the “issues that keep getting in the way” of her being hired for a job. She has been referred
to you to ultimately help her to secure and maintain employment.
During the assessment phase, you ask Jackie to complete a chart that describes her last
three job interviews, including her thoughts, her physical reactions, her feelings during the
interviews, and what she said to the interviewer. See Table 12.3 for her completed chart.

TABLE 12.3: Completed Chart for Jackie Using CBT

Interview Physical
Date/​Time Number Thoughts Reactions Feelings What Said/​Did
March 21 1 They will never Tired Hopeless Nothing; tried to
10:00 a.m. hire me. respond to questions
March 30 2 She thinks I am Butterflies Scared Just sad and hoped it
9:30 a.m. an idiot. in stomach would end soon
April 4 3 I do not know Sweaty Nervous Waited to see what they
1:00 p.m. what they want. palms wanted me to say

128 • Moving Beyond Assessment

 What emerges in the chart is that each time Jackie entered into a dialog with an inter-
viewer, she had thoughts such as “They will never hire me” and “She thinks I am an idiot.”
When she had those thoughts, she felt hopeless, and then she reported that she stopped
talking and just nodded her head rather than share her skills and competencies. As a result,
the interviewer did not have the opportunity to learn what Jackie had to offer to the posi-
tion, and ultimately she did not get hired. This result only confirms her belief that she will
not get hired. She then carries this strengthened thought with her to the next interview,
leading to the same cycle.
What may seem obvious to you (i.e., that these self-​defeating thoughts ultimately led
her to not get hired for a job) may not be so obvious to Jackie. Therefore, your task here is
to help her see how these thoughts led to her negative feelings, which led to her behavioral
response of shutting down during the interview, which eventually led to her not getting the
job. It is only after she has recognized the patterns identified in association to the main event
(the interview) will you be able to help her with this connection. This example used a cogni-
tive behavioral framework. As such, the information that was gathered on the chart focused
on thoughts, feelings, and behaviors—​all hallmarks of CBT.
Another approach would have been to gather information regarding interpersonal
styles. Table 12.4 reflects a chart that captures interpersonal patterns.
Using a relational framework that might be seen in numerous models, such as mental-
ization (Bateman & Fonagy, 2011) or Child–​Parent Psychotherapy (Bratton et al., 2006),
the focus in Table 12.4 is on Jackie’s interpersonal patterns and how those patterns relate to
the presenting issue. This chart demonstrates that if she is around an authority figure, Jackie
withdraws. In conversations with her, you find that this pattern has existed for as long as she
can remember, including in school with teachers, her friends’ parents, and any other adult
figure. In these situations, the pattern is the same; she perceives the adult to be in a position
of authority, and her style of engaging with adults is to withdraw and to be overly deferen-
tial, and in the job search ultimately leading to the same outcome—​she does not share the
information she has about herself with the interviewer, so she does not get the job.

TABLE 12.4: Interpersonal Chart for Jackie

Interview Description of What I think of That What I Think That Person

Date/​Time Number Person Person Thinks of Me What Said/​Did
March 21 1 Older She seems That I am stupid and Nothing; tried
10:00 a.m. female—​ scary. talking too much to respond to
maybe questions
50 years old
March 30 2 Older She looked That I should stop Just sad and
9:30 a.m. female—​ like she gets talking hoped it would
60 years old annoyed end soon
easily.
April 4 3 Older male—​ He seemed That I should Waited to see
1:00 p.m. 50 years old impatient. only answer the what they
questions he wanted me to
wants and no say
more

The Middle Phase of Treatment • 129

 As stated previously, the social worker’s job in the second step is to help the client to rec-
ognize this pattern and how it is not helping her to achieve her goal. The explanatory theory
used by the social worker will often shape the type of information that is captured during
the pattern identification, but it does not need to be exclusive. Theories reduce information
as a way to focus the work, but at the beginning, the social worker may use several theories
to gather the information necessary to help the client. Once the pattern has been identified
and linked to the presenting problem, the explanatory theory is used to explain how this
pattern emerged.

3. EXPLAIN BOTH HOW THE PATTERN MAY

HAVE DEVELOPED AND ITS PURPOSE
The third step involves helping clients to understand the whys behind the pattern: Why did it
develop in the first place? The amount of emphasis placed on this step varies depending on
the explanatory theory used. For some theories, like behavioral theory, the why behind the
pattern is less important than theories for that have derived from a psychodynamic base. The
reason for these differences lies in the assumptions of the theory: Does the theory assume
that gaining insight into the origins of behavior is important in creating change? If the answer
is yes, then more time is spent on this step. If the answer is no, then less time is spent here.
Regardless of the amount of emphasis placed on this step, we have found that clients are
relieved to understand that the pattern developed for a reason, and that it served an impor-
tant function in their lives at some point. They often feel relief or have an aha moment when
they realize that the behavior came from somewhere and when put into that context actu-
ally makes sense. For some of our clients, understanding why this pattern was useful to them
is one of the most valuable aspects of the work.
Returning to the case of Jackie, her history involved being raised by her paternal
grandmother, who was unhappy about having to raise another child after her own chil-
dren were grown. Jackie began living with her after her mother lost custody of Jackie after
a teacher at school became concerned about bruises she saw on Jackie’s arms and legs.
Her mother was addicted to drugs, and Child Protective Services determined that she
was also physically abusing Jackie. Although she came to live with her paternal grand-
mother, no one knew where her father was because he had never been active in Jackie’s
life. The state approached her grandmother, stating that she was the only suitable relative,
and if she did not take Jackie, the child would be sent to foster care. Jackie was 11 at the
time, and her grandmother immediately told her she was to “be seen and not heard,” as
well as not give her grandmother “any trouble” because if she did Jackie would be “sent
off to a foster home where you [she] would surely get abused.” So, while her grandmother
provided her with a home, food, and other basic needs, Jackie was isolated and learned
quickly that if she asked her grandmother for anything beyond the most basic of needs,
she was “too much.” Jackie learned not to ask much of her grandmother and quickly with-
drew from engaging with her.
Her grandmother did not encourage Jackie to bring over friends or encourage her to
play with other children outside the home. As a result, she was an isolated child; she had

130 • Moving Beyond Assessment

no other siblings and lived in a rural community away from many neighbors. Even prior to
living with her grandmother, Jackie’s mother’s long history of drug use left her alone often.
Jackie also reported that if she asked her mother for food or made other requests, she was
hit and told that she should “appreciate what you have.”
In the discussions of the previous intervention steps, we demonstrated how different
theories explain the current pattern and guide the information gathered. These theories also
explain why the pattern exists and the purposes it served. Using the case of Jackie, we have
discussed what information would be captured with both a CBT and a relational approach
in the previous steps. In Step 3, the theory also plays a significant role in helping to explain
the origins and purpose of the patterns.
CBT Approach. The CBT approach would explain Jackie’s pattern of withdrawing as
stemming from her core belief (or the main, raw, and unfiltered view she has of herself) that
she is unworthy. This core belief developed as a result of her experiences with her mother,
grandmother, and father, who all communicated to her that she did not deserve to have
her needs met and that no one really wanted her around. These experiences influenced the
development of schemata or thought structures. These schemata formed the lenses through
which she interprets and filters the information about herself, others, and the world. Her
core belief leads her to have automatic thoughts of “they will reject me” and “I am not good
enough.” When she thinks these thoughts, she feels hopeless and dejected, and the way she
has learned to cope with these feelings is to withdraw and further isolate herself, like she
does in the job interviews. Her family, who explicitly stated that she should not assert her-
self, also reinforced this pattern of withdrawal.
Relational Approach. The relational approach would explain this pattern by looking
at her current behaviors and how those were learned in her childhood. It is clear from
Jackie’s relationship history that it was protective for her to withdraw from others in
authority. Her early relationships included one with her mother, who abused her when
she asked for her needs to be met. Through this experience, she learned to suppress her
needs within relationships and wait for adults to provide for her. Moving to her grand-
mother’s house only solidified this pattern. She was again told that her needs were not
valued, and that she would be accepted and safe only if she remained withdrawn and
without needs. Through these experiences, she developed an interpersonal pattern of
deferring to and withdrawing from adults, as well as suppressing her own needs. This
pattern served her well as a child because by doing so she was not hit when she was with
her mother and while with her grandmother she was not sent to foster care where her
grandmother told her she would go. In her past, it was helpful for her to withdraw and
not be seen. Although she now is an adult and is not sitting with her grandmother or her
mother, she transfers these same experiences she had as a child to current interactions
and withdraws again.
In both of these explanations, although quite different, Jackie’s pattern makes sense. It
is hoped that it is obvious that, given her childhood, these patterns helped her survive in
the context in which she was raised; the pattern of withdrawing was an effective survival
strategy. However, what we also hope is becoming clearer is that while this pattern was help-
ful to her then, it is no longer useful to her. In fact, that same pattern that was so impor-
tant for her survival then is now causing her stress and challenges in finding employment.
Communicating this message is the key aspect of this step in the intervention phase. What
worked for the client in the past is no longer working or helpful to her in the present. To

The Middle Phase of Treatment • 131

reach their identified goal, the key is to change the identified pattern, which will lead to the
final stage of the intervention phase.

4. DEVELOP NEW PATTERNS

The final step of developing new patterns is in some ways self-​explanatory, but of course
challenging as it requires clients to do something different. Some clients are eager to change,
yet still struggle to do so. Some of the challenges to adopting new patterns stem from fear,
a lack of support in their network, or other barriers. For those who are not interested in
changing, this stage can be even more challenging for those invested in helping them address
their issues because these clients lack the motivation to put the time, effort, and energy into
making changes in their lives. We, along with every other instructor and clinician, wish we
had the magical solution for those clients who are unmotivated to change. As we noted
previously, in those situations it is important to find some common ground that can be
helpful in engaging them in the work. Many clinicians have found that using an approach
like Motivational Interviewing (Miller & Rollnick, 2013) can be helpful in these cases. It
would be impossible to try to anticipate all of the various challenges that social workers may
have in this fourth step. Therefore, we identify the key aspects of this step in the intervention
phase in hopes that it guides your work with clients.
The key to this phase is working with clients to do something different; even small
incremental changes can be powerful in changing the pattern. The tasks used to change
those patterns are often driven by the explanatory and change theories that you are using.
As discussed in Chapter 11, these two theories often go hand in hand. Your explana-
tory theory should be connected in a logical way to your change theory so that the link
between why you think the issue exists is connected to the pathway to alter it. It is during
this step of the intervention phase that learning different approaches to intervention can
be especially helpful. Each model will provide a different set of tasks that can be done
to shift patterns.
For example, we have used two different approaches to identify, link, and explain the
pattern that informed Jackie’s presenting problem. If we were using CBT to change the pat-
tern, our tasks would involve skills and strategies to change her thoughts and behaviors, as
these are areas that we assessed to be problematic for her previously. Therefore, by changing
the thoughts, Jackie’s feelings will change, which will result in a different behavior. If we
were using a relational approach, we would focus on shifting Jackie’s relationship patterns
through her experiences of different relationships, including your relationship with her. In
the professional relationship, you would provide her with a new or corrective relational
experience by which she could assert herself and be accepted. You would also teach her
assertiveness skills and have her practice these with individuals with whom she was ensured
a positive response, such as her vocational education counselor.
There are many different approaches to addressing client issues, and readers are encour-
aged to explore those further in coursework, continuing education, independent learning,
and supervision. Identifying an approach that is most appropriate for clients is trial and
error, but using the EBP process (see Chapter 10) is an excellent way to incorporate the

132 • Moving Beyond Assessment

client’s unique needs, your expertise, and the best available research as you and your client
decide on the approach. The specific strategies within the approach are the tasks that you
identify within your treatment plan (see Chapter 13).
Once you and your client have agreed on an approach, it is important to remember
that how you deliver the approach is a combination of the art and science of social work.
Through the use of EBP or other methods to infuse research into your approach, the art
is up to you. How you engage your clients in the phase, how you work with them to make
changes both during your time together and outside it, how you introduce and help them
master new skills, and much more are part of the art of social work.
This step can be frightening to clients. You may be asking them to do activities that are
frightening or disorienting. Even clients who are strongly motivated to change will at some
point have ambivalence about it. There is always some gain to the status quo and some loss
involved in changing. For example, when Jackie is able to get a job, she will lose the sup-
portive relationship with her vocational counselor and even need to terminate with you.
She knows what it is like to be unemployed and stressed about finding work, but can she see
herself being successful in a job and able to keep it long term?
Many clients speak to this ambivalence about change and fear of the unknown as the
phenomenon of “the devil you know is better than the one you don’t.” If you empathize
with this ambivalence, and not label the client as “resistant,” you are likely to help the client
reach his or her goals. It is important to “honor the resistance,” as it will help you to better
understand the origins of the ambivalence and be more effective in addressing it (Teyber &
McClure, 2011, p. 95). It will be especially important at this time for you to remember that
the relationship that you have with your clients is a critical factor in the success of whatever
approach you take (Wampold, 2010). Research has continued to show that the relation-
ship between the worker and the client is a critical component of a successful intervention
(Norcross, 2002). Through your support and by remaining attuned to the pace, their needs,
and the subtle changes in the work, clients will gain more confidence in their ability to learn
and master new skills and ultimately change their unhelpful patterns to more helpful and
adaptive ones.

CONCLUSION
This chapter discussed the middle phase of working with clients, often referred to as the
intervention phase. While there are many different approaches social workers can take to
work with clients to reach their goals, most of these approaches follow four steps: identify
the patterns; link the patterns to the presenting problem, issue, or concern; explain how the
pattern may have developed and its purpose; and develop new patterns. Each of these are
driven by the social workers’ explanatory and change theories and models (e.g., interper-
sonal, behavioral, cognitive) and as a result will involve different tasks to ultimately help
clients alter the patterns that are unhelpful to them in reaching their goals. Social workers
should work closely with clients to address any potential barriers to changing their patterns,
always in the context of a supportive relationship that balances the art and science of social
work practice.

The Middle Phase of Treatment • 133

CHAPTER 12 RESOURCE GUIDE
RESOURC ES
Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2004). The art and science of brief psychothera-
pies: A practitioner’s guide. Washington, DC: American Psychiatric Press.
Frew, J., & Spiegler, M. D. (2013). Contemporary psychotherapies for a diverse world. New York, NY: Routledge.
Gabbard, G. O. (2009). Textbook of psychotherapeutic treatments. Washington, DC: American
Psychiatric Press.
Gabbard, G. O., Beck, J. S., & Homes, J. (Eds.). (2005). Oxford textbook of psychotherapy. New York, NY: Oxford
University Press.
Messer, S. B., & Gurman, A. S. (2011). Essential psychotherapies: Theory and practice (3rd ed.). New York,
NY: Guilford Press.
Turner, F. J. (Ed.). (2011). Social work treatment approaches: Interlocking theoretical approaches (5th ed.).
New York, NY: Oxford University Press.
Walsh, J. (2013). Theories of direct social work practice (3rd ed.). Stamford, CT: Cengage.

134 • Moving Beyond Assessment

 CHAPTER 13

PLANNING FOR CHANGE

AND SETTING GOALS

I n our conversations with many practitioners, we have found that they rarely
establish a treatment plan that includes setting clear and measurable goals with clients. We
find this information remarkable and a bit disturbing for a number of reasons. Without
a plan, how will you and your client know how you will address the presenting concerns
together? Without a plan, how will you and the client know whether your strategy is work-
ing or not? Without a plan, how will your client, you, and others know what is expected of
everyone? Without a plan, how will you and your client even know where you are headed in
the intervention process or when it is time to end the work?
Imagine going to see your physician, a financial planner, or another type of service pro-
vider. Imagine yourself walking in the door to his or her office and asking for help with
an issue, such as a health issue or assistance with budgeting. Now, imagine if this person
listened well to your wishes and concerns and then simply said, “Why don’t you come back
next week, and we can continue talking about this issue?” Many of you would most likely
find this response frustrating. Your frustration may stem from wanting to have answers to a
variety of questions, such as, “What are the next steps?” “What should I be doing to address
this issue?” “What is the provider going to be doing to address the issue?” “Why can’t you
do something to help me today?” Clients are coming to you for help with a specific issue
and, rightfully so, want to know what action steps will be taken to address the issue. They are
most likely coming in now because they feel ready for change or have been told they need to
change now. Planning for change and goal setting is a critical stage of the work with clients.
This stage clarifies for everyone involved what the plan is for helping the client resolve the
presenting issue. Therefore, we encourage all of you to incorporate such planning into your
work with clients.
This stage of working with clients is often referred to as treatment planning. However,
many of you will not be working with clients in a treatment setting, meaning you will not
be providing psychotherapy services to your client. Whether you are working in a clini-
cal or macro setting, the phase that we are calling planning for change is the same across
settings. We were concerned that by referring to this phase as treatment planning many
readers might assume that these ideas only apply to those social workers who are working
with clients in a traditional therapy context. We believe that generalist social work practice
can be transformative regardless of the setting or type of service offered. Therefore, we want
to ensure that, regardless of the context, social workers include thoughtful planning in their
work with their clients.

BEFORE YOU START

There are a few important questions to ask yourself before you begin the planning phase.
These questions are listed next and should help provide a guide for when you are ready to
begin this phase of your work with clients.

• Are you clear about what types of services you and your agency can offer and what
you cannot?
• Have you thought through what potential triggers might emerge for you with
this client (i.e., what issues or topics could be discussed that might create strong
reactions in you)?
• Have you conducted a thorough assessment so that you are clear about what the
issues might be?
• Have you completed the evidence-​based practice (EBP) process so that you and
your client are clear about what types of interventions might be worth exploring to
help the client with his or her presenting concern?

Once you feel confident in your readiness to embark on the change process, you can begin
thinking about creating goals for your work together.
One important piece to remember during this phase, as with all other phases of work,
is to assess for and build on the clients’ strengths. As you are working toward helping
clients to address their presenting issues, it is essential that their existing coping strate-
gies and their capacities for success be considered. Asking clients about how they have
addressed these issues so far is a good place to start. You can also explore other changes
they have made and how they accomplished them. These strengths should be incorporated
into the planning stage as much as possible. Not only does including strengths provide
the social worker with a clearer baseline of where the client is, but also it is a way to build
confidence and momentum as clients feel more confident in their capacities to take on this
new challenge.
In addition to ensuring that strengths are remembered in treatment planning, it is
important to remember that this planning for a change process is a mutual undertaking.
Helping professionals should make every effort possible to have this stage be a collaborative
process that is driven by the clients and their needs. For some situations, this goal of inclusion
is a challenge. These situations include working with mandated or court-​ordered clients or
minors who are referred by a third party. When clients have not self-​referred, they may be
less invested in planning for the change process, as they may not believe that there is a need

136 • Moving Beyond Assessment

for any change. In such cases, we wish we could offer a magical solution to increase their
motivation. However, we cannot. There is some research that indicated that techniques
such as motivational interviewing (MI; Miller & Rollnick, 2012) are effective with invol-
untary clients in engaging them with the helping process. Whether you are using MI or
another approach, it is important to find a way to connect with clients concerning what they
want out of the process.
For example, imagine you are working at a social service agency with a parent
named Ms. K who has been mandated to receive parent education services because
of inappropriate discipline strategies. Ms. K does not believe that she was inappropri-
ately rough and is angry because she has to participate in this service. The agency has
identified specific outcomes that they want Ms. K to achieve before they are willing
to stop services. If she does not comply, the agency has threatened that it will remove
her children from the home. Ms. K expresses a great deal of anger and does not feel she
needs to work on any of the mandated goals. Given this perspective, it will be difficult
for her to plan for change because she does not feel she needs to. One way to approach
this type of situation is to join with her concerning that she wants the agency to be
out of her life. If this is her goal, what can you help her with in the process toward
achieving the goal of getting the agency out of her life? Sometimes by joining with her
concerning such a goal, there is a middle ground that can be found and a plan of action
can be established.
In essence, you want to acknowledge for the individual who is mandated that this per-
son does not want to be there. Yet, simultaneously, you also want to continue to work
toward his or her goals. Whether you are working with a teenager, child, or adult, the mes-
sage can be that you understand his or her ambivalence about being there, but there may
be some ways that the two of you can still find a goal or focus that might be useful to that
individual. A useful way to engage in this process is to say something such as, “Since you
have to be here, how do you want to spend this time in a way that benefits you? We have
to address xyz, but is there something you want to do with our time that you would find
valuable?”

SMART FORMAT
As you begin to think about planning for change-​oriented work with clients, it is important
to keep in mind several important components of the plans you will be writing together. As
you articulate the plan, it is important for the plan to be specific, measurable, achievable,
relevant, and to have a time frame, also referred to as SMART (Doran, 1981). The SMART
format in direct practice has been borrowed from macro practice focused on project man-
agement as a way to ensure that projects are clearly articulated and manageable (Doran,
1981; Meyer, 2003). The acronym remains the same as first articulated by Doran over
30 years ago:

• Specific—​clearly articulate what will be accomplished. The goals, objectives, and

tasks should answer the questions of what, when, where, and how. They should also
specifically address who will do what.

Planning for Change and Setting Goals • 137

 • Measurable—​The process will quantify in some way how progress or achievement
will be assessed.
• Achievable—​The goals are attainable and appropriate given the client’s context,
capacities, motivation, history, and any other relevant factors that should be
considered.
• Relevant—​Do the goals link to the issue of the client? In addition, are they realistic,
and do they resonate with the client’s wishes?
• Time frame/​time bound—​There needs to be a time frame established for when the
plan will be achieved, with specific time frames for each stage of the process.

Since Doran (1981), others have added an R at the end to create SMARTR goals, with the
R representing reevaluate to emphasize creating and working toward goal attainment as a
dynamic process (Yemm, 2012). The SMART or SMARTR format should be applied to
all parts of the final document that represents the plan for the work together, including the
goals, objectives, and tasks outlined in the document.

GOALS, OBJECTIVES, AND TASKS, OH MY!

In our work with students, we have found that clarifying the differences between goals,
objectives, and tasks is a constant challenge. These three components of an intervention
plan seem to become muddled and confused by practitioners, yet they represent distinct
components of a plan for change. We hope that by the end of this chapter we have clarified
these important and distinct entities of a plan.

GOALS
Simply put, goals are where the client wants to be at the end of the process. We often refer
to a goal as similar to the destination you might put in your GPS. For example, if you are in
Washington, D.C., there are lots of places you could go from that location. Getting in your
car and starting down a road might be an interesting adventure, but without a goal or desti-
nation, it will be a meandering experience. Therefore, it is important that we help clients be
clear about where they would like to be by the time the work together ends.
While it may sound easy in theory to establish goals with clients, it is actually harder
than it appears. Clients often focus on what is not working; therefore, it can be difficult to
have them shift to what they want or what would be better. Sometimes, it is hard to imagine
what they want as they and everyone else has spent so much time focused on what they do
not want. It can be difficult to articulate those hopes in a way that is meaningful and real-
istic given all of the contextual factors in their lives. Therefore, clients may need your help
to articulate their goals in a clear fashion. However, as stated previously, it is important to
ensure that this process is collaborative. While clients may need help articulating their goals,
the goals you establish should not be yours. Every effort should be made to have the client
take ownership of the goals rather than have the goals comprise your wishes for them. To

138 • Moving Beyond Assessment

help with this process, we have the following guidelines that we hope will help you in your
goal creation process with clients:
Goals should be linked to the target concerns: Goals should connect directly to
the client’s presenting issue or, in the case of mandated or involuntary clients, those goals
that are stated by the mandate or court order (Hepworth, Rooney, Dewberry-​Rooney,
& Strom-​Gottfried, 2013). There should be a clear link between the target issue and the
goal that you are creating with the client. In addition, goals should be consistent with
the client’s wishes as much as possible rather than yours or anyone else’s. For example,
if an individual is struggling with test anxiety and was sent to you, the school social
worker, for help with this issue, the goal should be related to managing test anxiety and
pressures at school, not something outside academic issues, such as managing friendship
dynamics.
Goals should be written in the positive: Goals should be about what people want
rather than what they do not want. As stated previously, clients have often spent so much
time focused on what is not working it can be difficult for them to imagine what they want
instead. This struggle is where you can help. They may need help in focusing what they want
instead of what is currently happening. The distinction is subtle, but important.
Another way to make this distinction is through an expression that is used in the field
called “the Dead Person Rule” (Spiegler & Guevremont, 2010, p. 57). If a dead person can do
it, then it is not an appropriate goal. For example, a dead person can stop drinking but cannot
increase coping capacities to manage sobriety. A dead person can stop cutting or self-​harming
behaviors but cannot learn to regulate his or her affect. A dead person can stop fighting but
cannot learn how to use “I statements” to increase positive communication. Therefore, you
may need to help your clients find ways to express their goals in positive and active language
that will help them articulate what they want to see at the end of your work together.
Goals should be future oriented: While this guideline may sound obvious, you may
find that some clients are heavily focused on the past and wish to change parts of the past.
They may need to help refocus their attention on the future and where they hope to be
rather than where they wish they were. For clients who struggle with loss or depression,
this aspect of creating goals can be especially challenging. Yet, creating goals is about look-
ing ahead and articulating where you want to be in the future, so it should be focused on
looking ahead rather than looking back. For example, if you are working with a survivor of
sexual violence, the client may set a goal of returning to a normal life like before the assault.
Turning this goal to be future-​oriented would mean that the client would work on inte-
grating the traumatic experience into his life so that it did not define him or his behaviors
moving forward.
Goals should be time limited: Goals should be given a time frame. Not only does
this help you and your client stay focused, but more often than not, third-​party payers (i.e.,
insurance companies and Medicaid) require that the work we do with clients be time lim-
ited. Time limited does not need to translate as brief, although it can. What we mean here is
that you and your client should set a realistic time frame for when you anticipate the goal to
be achieved. Ideally, the issue and the client’s capacities and motivation to address that issue
would determine the date. However, it is more often the case that dates are chosen because
of external pressures, such as the end of the academic school year (either for the social work
intern or the clients), or by the policies of the third-​party payer that limit the amount of time

Planning for Change and Setting Goals • 139

for the intervention. In the best case, you would set a time limit on a goal based on what is
realistic for the client. A goal statement with a goal would then include the goal along with
the time frame, such as increasing the client’s capacity to take her medications regularly by
December 31.
Table 13.1 provides you more examples of goals. As you will see from the examples,
goals can be and should be simple. The more specific you can be and the simpler you can be
in the language, the easier it will be to remain focused and not become distracted by trying
to do too much.

OBJECT I VES
Objectives are the part of the plan for change that operationalizes the goals. They serve
as concrete, measurable, and objective markers that you will use to identify whether
you are moving in the right direction. Objectives can be short or long term, but in
either case, they should be clear about how the outcome of the intervention will be
measured. Goals are often seen as the conceptual or big-​picture view of where you want
to go, while objectives are the milestones used to determine whether you have achieved
those goals.
Going back to the GPS metaphor with you in Washington, D.C., let us say you have
identified your goal as wanting to get to the Brooklyn Bridge in New York City. It is clear
where you want to go, and everyone has agreed that this location is the final destination.
As you start your journey to the Brooklyn Bridge, there are lots of ways that you can get
there, but how will you know if you are heading in the right direction? Well, you could look
at your GPS and see whether it visually shows if you are on the right track. You could use
a compass and check it regularly to see if you are still heading in a northeastern direction.
You could look for signs along the interstate to see if the signs are for New York, as well as
other approaches. Each of these helps you determine whether you are getting any closer to
your goal.
Objectives in social work serve the same purpose. They are used to provide real-​time
evaluations of where you are in relation to the goal. If, for example, the client’s goal is to
increase her coping capacities to more effectively manage angry and violent outbursts,
how would you and she know if what you are doing together is working? A possible
objective might be to count how many fights she gets in over a period of time and com-
pare that rate to a baseline rate. Another option might be to have her use an objective
measure to self-​assess the number of skills she uses in her day-​to-​day life with regard to
her emotional regulation. The chapter on endings provides a more thorough discussion
of ways to measure the outcomes, which are often similar to the objectives used in the
treatment plans. The tools described in that chapter provide you and the client with
concrete measures of progress.
Objectives are often used in conjunction with the phrase “as evidenced by” (AEB). This
phrase is commonly used in plans for change to demonstrate how the attainment of the goal
will be identified. Social workers should ask their supervisors whether this phrase is used
within the agency. It is essentially saying that you will know that the person has reached her
goal AEB a particular outcome or milestone, which is then listed in the plan as the objective.

140 • Moving Beyond Assessment

 As a guiding principle, most plans include at least two objectives for each goal to ensure
that there are multiple markers for measuring the goal. While it is easy to ask the client if
he or she believes that the treatment is working, this is often not the best measure of prog-
ress for a variety of reasons. The chapter on endings provides a thorough discussion about
self-​report options, and readers are encouraged to review that section if planning to use
self-​report indicators.
Regardless of what types of objectives are used in plans, the key is to make sure that they
are accurate indicators of progress. Including an objective that does not actually assess for
progress toward the goal is not helpful. Using our trip to the Brooklyn Bridge, asking our-
selves whether we are having a good time on our journey will not provide us with informa-
tion about whether we are moving closer to the Brooklyn Bridge. Also, asking us whether
we think we are heading in the right direction based on our internal compass is also not an
objective way of measuring progress. Therefore, when choosing objectives, it is important to
consider whether they are objective (versus a subjective measure) and a relevant outcome
related to the goal. See Table 13.1 for how the objectives are phrased and aligned with the
goals identified.

MODAL I TY
The modality of intervention is sometimes included in treatment plans, but often not. We
have chosen to include it here as we believe it is another way for social workers to be trans-
parent with clients and their caregivers about what will be happening in the work together
with the client. What we mean by modality is the approach that you will be using when
working with a client. Sometimes, modality is referred to as the broad category of inter-
vention that will be used, such as individual, group, or family levels of intervention. Other
times, the modality of treatment is referred to as the specific practice model that will be
used in the work with the client, such as psychodynamic therapy, cognitive therapy, or case
management. Social workers should discuss with their supervisors regarding what should
be reported on the plans for change.
Regardless of which definition is used, the modality of intervention outlines which
approach will be used to reach the client’s goal. Returning to the goal of reaching the
Brooklyn Bridge from Washington, D.C., there are many modalities that you could use to
get there. You could drive, take a plane, walk, bike, take the train, or even arrive by horse-
back! For many clients, knowing how you will get there is comforting.
Regardless of which modality you use, the objectives and goals remain the same. You
still want to know if you are moving in the right direction and getting closer to your goal. If
the client’s goal is to increase his or her coping capacities to more effectively manage angry
and violent outbursts, you can achieve that goal through group therapy that utilizes psy-
chodrama, individual therapy that uses cognitive behavioral therapy (CBT), or a family
approach that looks at the issue from a systemic lens. Which approach you use will be deter-
mined by the EBP process that incorporates relevant client factors; your expertise, which
includes your knowledge of theories and practice models; the best available evidence; and
the contextual factors that are relevant to this client’s life (see the chapter on EBP for a more
thorough review).

Planning for Change and Setting Goals • 141

 TASKS
Once you have determined your modality, the tasks that you will use often fall into place.
Different practice models will often provide tasks that are linked to the theory of change.
These tasks or intervention strategies are then used to create the desired changes or goals
that have been set. For example, in a CBT approach, some of the tasks would include identi-
fying cognitive patterns and then learning new skills to change those patterns. The timelines
for completing these tasks and the specific instructions for these tasks are what is placed in
the tasks section of the plan for change. The social worker, based on his or her assessment,
will determine which tasks have the potential to be most relevant in helping the client to
achieve his or her goal. Ultimately, these tasks should link back to the client’s goals that
were based on the assessment using a specific practice model, which is based on a theory of
change that is linked to an explanatory theory. This last statement should sound familiar as
it comes from the previous chapter on the use of theory.
To close our metaphor with trying to reach the Brooklyn Bridge from Washington,
D.C., the specific tasks we would need to undertake to get there are based largely on
the modality we have chosen. If we decide we want to arrive by plane, then we need to
purchase tickets that will get us there by the date of our goal. Another task would be to
figure out how we will get from the airport to the bridge. If we decide that our modal-
ity will be by bike, then we have an entirely different set of tasks, which involve food
storage, equipment, identification of safe bike routes, assessment of fitness levels, and
much more. We will let you play out the tasks that would be necessary for the horse-
back option.
Please refer to Table 13.1 for examples of potential tasks. The ones listed are just exam-
ples and are not meant to be comprehensive of what might be included in a plan for change.
They are simply to give examples of potential tasks that might be included. There are often
many more tasks than just two for each goal. You may also note in some of the examples that
the social worker is named as someone who will be completing tasks. The social worker,
family members, physicians, and others may all be listed as individuals who have a role to
play in the plan and should be included when appropriate.

TYING IT ALL TOGETHER

As you can see, there are numerous potential tasks that could be used to achieve the same
goal. These tasks are determined by the modality that has been chosen, ideally through the
EBP process. Regardless of which path is chosen, the clients and social workers need to
identify objectives that will provide markers for their progress toward reaching the goals
set by the clients. For each of these aspects of the plan, the SMART format should be used
throughout. The SMART or SMARTR format can be used to ensure that, for each of the
sections of the plan, you have been specific; provided measurable goals, objectives, and
tasks that are achievable and relevant; as well as have a time frame for each.

142 • Moving Beyond Assessment

TABLE 13.1: Examples of Goals, Objectives, and Tasks With Modality Identified
Example 1 Goal: Client will increase her support networks by 50% the end of 6 weeks.
Objective 1: By the end of 1 month, the client’s list of individuals and community resources that
she considers a support will be 30% higher than at baseline.
Objective 2: Client’s family will report a decrease in phone calls by at least 50% compared to
baseline by the end of 1 month.
Modality: Individual case management
Task 1: Within the first week, client will compile a list of her current supports, either
individual or community agency support.
Task 2: In the second week, the client will identify at least three individuals or organizations
that she will contact that she believes could serve as a social support.

Example 2 Goal: Client will increase his social skills to more effectively manage conflict with
peers in school by the end of 6 months.
Objective 1: Teachers will report a decrease in peer conflicts at school by 50% by the end of the
first quarter.
Objective 2: Parents will report a decrease in peer conflicts in the community by 75% by the
end of 4 months.
Modality: Structural family therapy
Task 1: Within the first week, the family will identify the rules and consequences at home for
both desired and undesired behavior.
Task 2: Within the first month, the parents will chart the number of conflicts with peers
in their community and family, their responses to those behaviors, and how the client
responded to those responses.

Example 3 Goal: Client will secure stable housing by the end of 6 months.
Objective 1: Client and social worker will have a list of possible housing options by the end of
1 month.
Objective 2: Client will have made at least four phone calls to explore different housing options
by the end of 2 months.
Modality: Individual case management
Task 1: Within the first week, client will compile a list of supports and barriers to finding
secure housing.
Task 2: In the second week, the client will brainstorm with the social worker ideas for how to
address the identified barriers.

Example 4 Goal: Client will increase her capacity to manage symptoms of anxiety at the end of
9 months.
Objective 1: Client will show a decrease by at least 10% on the XX Anxiety Rating Scale by the
end of 2 months.
Objective 2: Client will report a decrease in panic attacks from her baseline by at least 50% by
the end of 6 months.
Modality: Individual therapy using cognitive behavioral therapy
Task 1: Within the first week, social worker will provide psychoeducation concerning anxiety,
panic attacks, and the CBT model.
Task 2: Starting in the first week and for the next 2 weeks, the client will complete a thought
record to record at least three times/​week periods of anxiety. The chart should include the
time/​day and the thoughts, feelings, and behaviors that the client noted at the time.
A FINAL CONSIDERATION
We recognize that we have provided a description of the ideal scenario of treatment plan-
ning. There are many situations, such as in a crisis, for which you may not be able to walk
clients through such a clear process. There are also other limitations, like a client’s severe
mental illness or cognitive limitations, for which you might need to modify the planning
process. There are some models of intervention, like the Recovery Model (Deegan, 1988),
that specialize in having you think about how to modify and challenge our ideas of “inter-
vention” when working with unique populations. While we want to emphasize the impor-
tance of finding ways to follow the process we have described, it is also important to be
client centered and flexible when working with clients in assisting them to reach their goals.

CONCLUSION
A comprehensive and well-​thought-​out plan for change is the foundation for being able
to then evaluate the effectiveness of the approach you and your client have chosen to take.
Much of the work needed to do the final stage of the SMARTR format involving reevalu-
ating is already done. In Chapter 15 on evaluating practice, we provide a more thorough
discussion of how to evaluate both the progress your clients are making toward their goals
and how to determine if they are ready to end the work you have been doing together. The
time invested in drafting a useful plan will serve social workers well as they then move to the
intervention phase of the work, which requires continuous monitoring and evaluation to be
consistent with our own profession’s code of ethics.

144 • Moving Beyond Assessment

 PA R T I I I

ENDING WITH CLIENTS

 CHAPTER 14

ENDINGS

T here is a funny mock exchange between a therapist and a client in an

article called the “The Last Session” (Kenny, 2008) that was published in The New Yorker
(http://​w ww.newyorker.com/​magazine/​2008/​01/​28/​last-​session). It is written as a dia-
log from a session when the client comes in to discuss ending with therapist. The therapist
displays a host of inappropriate behaviors throughout the session while simultaneously
managing to completely avoid talking about ending the relationship. In the end, after
many examples of avoidance and unhelpful exchanges, the therapist states, “We have
to stop. Let’s pick up here next week.” The exchange in the scenario is disconcerting for
many reasons and underscores many of issues we addressed in the previous chapters (i.e.,
boundaries, self-​d isclosure, use of self). The piece is obviously meant to be humorous as it
highlights some of the stereotypes that are held about therapists. However, these stereo-
types are not limited only to social service providers practicing psychotherapy. Even with
the best intentions, all social workers, regardless of the type of social work service we are
providing, could fall prey to some of these behaviors in our work with clients. Some of the
most egregious stereotypical behaviors illustrated involved the portrayal of a therapist
who had no plan for ending with a client, had no methods to determine whether the work
with the client was having a measurable impact, and was unable to have a conversation
about whether the client had met any concrete goals through their work together.
This chapter is designed to ensure that your work with clients will not follow the same
path as the therapist portrayed in that scenario. Although we recognize that every situ-
ation is unique, in this chapter we provide some concrete guidelines to help direct your
termination process with your clients. While we have separated the chapters on termina-
tion and evaluating one’s own practice, the two chapters go hand in hand. Therefore, we
encourage readers to consider the chapters as two sides of the same coin as it is impossible
to extract one from the other.

THE WORD TERMINATION

Take a minute and think about what associations you have with the word termination. Are
these associations pleasant? Negative? What images come to mind? For many people, the
word termination conjures up images of being fired, eliminated, cut off, and removed with a
sense of finality. If these images are consistent with what you identified, keep in mind that
they may be similar for your clients as well. Given these associations, it is essential
that social workers thoughtfully approach termination with clients. We want to ensure
that this ending is different from other endings so that clients are not left feeling rejected
and abandoned. Although the word termination is used in the literature, we often prefer to
use the word ending. We use termination here to stay consistent with the literature, but we
encourage you to think of your own phrase or use ours to communicate the ending of the
work while finding ways to remove some of the harshness from the language.
In addition to attending to your clients’ associations with the word termination, it is
important to pay attention to your own associations, such as the images you identified
previously. How do you “do” endings? Are you typically able to talk through these expe-
riences in your personal life, or do you avoid them at all costs? The ending of a helping
relationship is unique. We do not typically end relationships that are working well for us
or that we feel good about. How often have you called up a friend and said, “This friend-
ship has been really great for me. You’ve been supportive and really fun, and I’ve enjoyed
spending time with you. However, at this point I feel I have done all the work as a friend
I can do with you, and it is time to terminate our relationship.” No one does that! It is an
experience not found outside the working relationship between client and practitioner.
How you feel about endings has the potential to influence how you end relationships.
It may be that you avoid talking about termination because of your own discomfort with
endings in general. It could be that you eagerly bring up termination because of the feel-
ings you have about a particular client. How social workers manage the endings of rela-
tionships with clients is a combination of both their own feelings about endings and their
feelings about particular clients. Therefore, it is critical that you use your self-​awareness to
recognize how this combination can directly influence the work with clients.

WHEN TO START THE TERMINATION PROCESS

In reality, the termination process begins during the first meeting with your clients or as
soon as you have created a contract for whatever service you are providing. We discussed
in Chapter 12 how creating concrete and measurable goals using the SMART (specific,
measurable, achievable, relevant, and with a time frame) format is an important step in
the process. In creating such goals, you and your client have already identified the path
you will take to reach the client’s goals. The objectives you and your client developed
established concrete outcomes that will identify whether the goals of the work have been
met. Therefore, the time invested in creating such concrete objectives at the beginning
stages of the work with clients has a direct impact on the termination process.
Unlike “The Last Session” (Kenny, 2008) scenario in which the therapist and client
have been meeting for 20 years, the vast majority of you will never see clients for that
length of time. This stereotype of the work that social workers do with clients is just that, a
stereotype. In reality, most often you will be working with clients for a shorter, more spec-
ified length of time. This time frame may be determined by a number of factors, including

148 • Moving Beyond Assessment

their insurance plans, which could be private, Medicaid, Medicare, or some other third-​
party payer. Other factors may be the realities of their lives. Many clients do not have the
time or the money to see a social worker for years. Clients have jobs, child-​care responsi-
bilities, and other obligations that make it impossible for them to have this type of service
for such a long time.
Now, although we have just explained that this length of time is a stereotype, we do not
want to imply that some clients do not need to have services on a long-​term basis. There are
many clients who can benefit from services for many years. However, the key phrase here
is that they continue to benefit from services. Our Code of Ethics (National Association
of Social Workers; NASW, 2008) states that we must provide services that are effective
(Section 4.01). Yet, there are many examples that we have seen in our years of practice of
clients continuing to receive services, yet it is unclear what they are gaining from those
services. Part of our responsibility as professional social workers is to regularly discuss
the progress the clients are making toward their goals. In these discussions, we need to
recognize that goals shift and the treatment contract may need to be adjusted, which may
alter the course of the intervention. Our Code of Ethics also states that if clients are no
longer benefiting from services, we must terminate services or transfer to another service
or provider (Section 1.16). Therefore, we support clients receiving services on a long-​term
basis as long as it is clear that the client is still benefiting from those services. We do not
want to create a working relationship in which the client is dependent on the practitioner.
As stated previously, evaluating one’s practice is a critical aspect of termination. To that
end, we discuss how to evaluate whether the provided services are effective in Chapter 15.

TYPES OF TERMINATION
As stated previously, the termination process should begin as soon as the contract is cre-
ated. In an ideal world, the client and the worker have identified a time frame for the work
and the specific objectives that will be reached by the end of that time. When the client
has met those goals and objectives, the work together ends. In some cases, you and the cli-
ent might end before the set date once the client is confident that he or she is able to reach
the stated goals independent of the social worker. These examples, albeit ideal, are of one
type of termination referred to as a planned termination (Gambrill, 2013). The worker and
the client have planned together for when the work will end. Together, they have planned
for the ending using the predetermined date in the treatment contract or based on the
agreed-​on outcome. In a planned termination, everyone is clear regarding when or under
what circumstances the termination will occur.
Other types of planned terminations include endings that are based on external fac-
tors that may be unrelated to reaching the agreed-​on goals. Such factors might include the
worker leaving the agency (i.e., an internship is ending or the worker is leaving the area),
the client moving, or the insurance company setting a number of predetermined sessions.
While these scenarios may not be ideal as they are not based on the client’s needs, these
still qualify as planned terminations because the worker and the client both know that an
end date is approaching and can plan ahead for that date.

Endings • 149
 For planned terminations, we created the guidelines shown in Table 14.1 to help you
create a plan with the client. However, these are meant as guidelines and, as with all of the
guidelines in this book, should be used in consultation with your supervisors. In addition,
all guidelines should always be considered in the context of your specific client and his or
her circumstances, as well as the mission and standard of care for the agency.
The other type of terminations that occur more often than we would like are referred to
as unplanned terminations (Gambrill, 2013). These are exactly as they sound, unplanned, and
can often leave both the worker and the client feeling like the work is undone. Unplanned
terminations can occur for a number of reasons. Some examples include situations when
the client just stops showing up for any number of reasons or the worker has an unexpected
personal emergency, such as an illness. With unplanned terminations, there are no oppor-
tunities to reflect on the work together or plan for how to say good-​bye. The lack of ritual
or reflection can often leave the worker feeling a range of different emotions, including
anger, relief, guilt due to feeling “I should have done more,” sadness, and self-​doubt, among
others. When I (E.D.) was supervising student interns at a local nonprofit agency providing
counseling for trauma survivors, it was common for students to express a lot of self-​doubt
when clients would just stop coming without explanation. The student would often discuss
these reactions in supervision; many would ask questions like the following:

• “Did she just not like me?”

• “Did I say something wrong?”
• “Am I just no good at this?”
• “Will I ever be able to keep a client engaged in the work?”

TABLE 14.1: Planned Termination Guidelines

Guidelines to Follow for Planned Termination in Consultation With Your Supervisor

•  Identify at the contract phase what the objectives are that you and the client will use to
measure goal attainment (see Chapter 12 on creating goals).
•  If there is a predetermined date for termination, remind clients at regular intervals regarding
this date and the remaining time.
•  If there is no predetermined date for termination and the treatment is based on goal
attainment, identify tools to measure outcomes and time frames for their use.
•  Discuss the client’s confidence in his or her ability to continue to reach his or her goals
without the social work service.
•  Depending on the time frame, approximately 1 month from the end of the service, discuss
with the client potential rituals or ways he or she would like to say good-​bye.
•  Depending on the time frame, if additional services are needed, begin planning at least
1 month in advance to prepare a “warm handoff” to the next provider.
•  Process rituals, plan for the ending, and your own feelings with your supervisor.
•  Anticipate with your client what feelings, behaviors, concerns, or patterns they might have
as the final session approaches (i.e., cancel last sessions, feel angry).
•  Normalize these feelings with your client. Even when the termination is planned far in
advance, it is normal to have feelings about the ending that can be complex.
•  Document every step of the process, especially the plan for after the final session, whether
they will be working with another provider, or if they have been given contact information for
how to connect to another service provider.

150 • Moving Beyond Assessment

We, along with many other highly seasoned practitioners, have experienced unplanned
terminations. These endings may in fact have to do with something that the practitioner
did or did not do. However, there are many circumstances that may contribute to the
premature end of the work and that have nothing to do with the skills or the “likability”
of the social worker.
It is important for social workers, especially interns and new workers, to consult with
their supervisors or other senior colleagues within the agency to create a plan for how
to respond to an unplanned termination. These terminations could also include mini-
terminations that stem from something in the practitioner’s life, such as a long vacation,
maternity/​paternity leave, or a leave of absence due to an illness. It is possible that the
feelings you have about termination listed previously may influence your own judgment
about how to best respond to the situation. In addition, there may be safety issues or other
situations that may influence how much more outreach the social worker or the agency
feels compelled ethically or legally to provide to the client. Regardless of the plan of action
that has been developed, it is essential that the decisions made by you, your supervisor,
or your agency be documented clearly in the client’s file, including any follow-​up commu-
nication between any individual from the agency and the client. The key message for you
to remember is to document every decision and any communication between the agency
and the client; each phone call, e-​mail message, or other written communication should
be documented and dated and placed in the client’s file. Table 14.2 provides guidelines for
unplanned terminations.

TABLE 14.2: Unplanned Termination Guidelines

Guidelines to Follow for Unplanned Termination in Consultation With Supervisor

•  If a client stops coming to meetings:
•  Consult with a supervisor regarding the policy on contacting clients (i.e., letters versus e-​
mails versus phone calls).
•  Discuss with your supervisor how often and the appropriate number of times the client
should be contacted.
•  Inform your supervisor of any safety concerns, such as suicidal or homicidal ideations,
potential for physical abuse (either as a victim or as a perpetrator), risk of alcohol or drug
relapse, or other safety concerns.
•  Document every attempt at communicating with the client.
•  Document every discussion/​consultation with senior colleagues regarding how each
decision was made about communicating with clients or ceasing communication.
•  If the social worker has a personal issue that results in an unplanned ending,
•  At the start of your internship or employment, discuss with your supervisor the emergency
coverage policy for the agency.
•  Become familiar with this policy and inform in writing each of your clients so that they
know who to contact if you are unavailable.
•  If you are able to contact clients, remind them of this policy and provide them with the
name of the appropriate contact person who will help them when you are unavailable.
•  If you will not be returning to the agency, discuss with your supervisor how to contact the
clients and what should be shared with them regarding why you are not coming back to the
agency.

Endings • 151
PROCESS OF TERMINATION
In addition to the timing of the termination, it is important to think about the termina-
tion process itself (Bogo, 2006). While there are many aspects to consider in the process
of saying good-​bye, there are four main tasks to consider: (a) review the process of the
work together; (b) consolidate gains; (c) plan for next steps; and (d) process the emo-
tional bond (adapted from Bogo, 2006). The opportunity to consider the process in termi-
nation occurs when there is planned termination, and we encourage all readers to process
each of these aspects with other colleagues or supervisors before doing so with a client.
(The following discussion is adapted from Bogo’s 2006 steps.)

REVIEW PROCESS OF THE WORK

As we stated previously, much of the work for knowing when the client has reached his or
her goals is done at the beginning stage of the work together. We discuss in the next chap-
ter more specific methods on how to evaluate whether the goals have been met. While
identifying whether goals have been met is important, it is also important to remember
that there is more to this phase of the termination process. Reviewing the process of the
work you and clients have done together also means you need to take time to consider
what specifically has changed. What have your clients noticed? What is different? In addi-
tion to noting the changes, it is important to note to what they attribute the change. What
changes have they made that they believe have had the greatest influence on their ability
to reach their goals? In other words, what have they taken from this experience that they
feel is especially useful to them?
Another piece of this stage of termination is to help the client identify areas that
remain a challenge. It is important to note these areas for a couple of different reasons.
First, it is helpful to normalize the reality that not everything is “perfect,” and while
the work the client has done at this stage has been helpful, not every issue has been
resolved. Second, this discussion leaves the door open for clients to return to you, the
agency, or another service provider to work with them in the future should they need
additional assistance with the same issue or a different one. Finally, a third reason is
to help them anticipate and then plan for potential setbacks. In many fields of practice,
clients work on relapse prevention plans (Beck, 2011; Steen, 2001) with their social
worker as they move closer to the planned termination date. These plans are concrete
tools with which clients can document potential challenges and what they will do to
address those in the future, which could include using a particular skill or contacting
a support person.
Ideally, the relapse prevention plan and the review process highlight and celebrate the
client’s strengths. Social work is a strengths-​based profession (Corcoran, 2011; Miley,
O’Melia, & DuBois, 2013; Shulman, 2012); yet, it can be easy at every stage of the work
with clients to remain problem focused. It is our job therefore to remain our clients’ big-
gest cheerleader and celebrant of their strengths and their numerous capacities. Noting
even small changes can encourage clients to feel empowered to continue the work they
have done with the worker beyond the termination phase.

152 • Moving Beyond Assessment

 CONSOLIDATE GAINS
Consolidating gains means helping the client develop a narrative of what the client learned,
gained, and achieved in your work together. Ideally, the client would be able to identify
what has changed and be able to compare where they are now to where they were at the
start of your work together. As you highlight and celebrate their strengths and achieve-
ments, it is also important to help the client take ownership for the work that they have
done with you (Bogo, 2006). Some clients, due to their cultural or social background, may
give the majority of the credit to the worker. While it is important to acknowledge your
role, we see the practitioner’s role as a facilitator and a partner in the process. The work
that clients have done is theirs, not ours. We are privileged to have been part of their pro-
cess. In your own way, you can convey this message to the clients as you process the end
of your work together. It can also be helpful to share what you have learned from them or
how working with them has been a positive experience for you.

PLAN FOR NEXT STEPS

For some clients, ending the work with the social worker may mark the end of services. If
this is the case, it is important to discuss with the client what to do should he or she feel
the need for additional support in the future. Can the client return to the same agency?
If so, what are the actions he or she should take? If either of you anticipate that the client
might need crisis services, the appropriate information about these services should be
provided at this time. It is imperative that the worker create a balance of conveying to
clients that he or she has confidence in the clients’ capacities to manage on their own,
while also preparing for any future challenges and identifying appropriate supports
before they leave.
Other clients will need additional or ongoing services beyond the work that you have
done with them. In that case, it is essential to anticipate these needs well in advance of
the final meeting with you. Careful planning with your client or the client’s caregivers
will reduce the client’s anxiety and be helpful in preventing potential gaps in services or
crises. We next provide a list of what to consider when planning for ongoing care. We
have not given any time frames for these tasks as they will depend greatly on the context
of the work you are doing with your clients. It should be assumed that the more time you
can allow for each task, the better the transition will be. With each step, the social worker
should document in the client’s chart every action taken.

• Create a list of needs the client will have at the end of the work.
• Obtain signed authorizations to release any relevant information to future
providers.
• Contact any other providers, caregivers, or individuals who are involved with the
client (i.e., physicians, teachers, juvenile justice providers) and discuss with them
the plans for termination and continuation of care.
• If the client is under a physician’s care for medication, discuss with the client
and the physician any potential needs, such as prescription refills or follow-​up
appointments.

Endings • 153
 • Identify any impact a change in services may have on the client’s finances, either a
change in cost, including a copay change, or if their insurance (including Medicaid
or Medicare) pays for the services in a similar fashion. Any potential change
in cost should be discussed clearly and explicitly with the client and/​or
caregivers.
• If the client will be continuing his or her care with a new provider, the social
worker should facilitate a dialogue regarding how to create a smooth transition.
In some cases, it might be helpful to have the client meet the new provider prior to
the final meeting, while in other cases, it may be more appropriate to wait until the
work with the first social worker has been completed. Each client’s needs should be
considered on an individual basis.

PROCESS THE EMOTIONAL BOND

Depending on the work you are doing with clients, this final task of processing the emo-
tional bond (Bogo, 2006) may seem strange or only reserved for situations for which you
are providing psychotherapy. Yet, we argue that social workers should not underestimate
the impact that we can have on the lives of clients, even in brief relationships that involve
what appear to be “only” concrete services. Imagine if you have been hospitalized for a
physical illness that emerged suddenly. It is easy to envision that you might feel scared,
overwhelmed, worried, and anxious about what the future could hold for you. Then, imag-
ine if a social worker came to you and helped normalize your feelings, helped you identify
your needs, used their knowledge to assist you with planning for those needs, and pro-
vided you with information about what to expect socially, emotionally, physically, and
relationally. It is easy to see how having such an exchange with a social worker, even if over
a short amount of time, could create a sense of relief, comfort, and gratitude and even an
emotional bond. Therefore, while it is easy to see how a bond can be formed when work-
ing with a client over a longer period of time, it is important that we do not dismiss the
possibility that a bond can be formed quickly between a client and a social worker. A key
ingredient in the work we do with clients is the relationship we form with them (Bogo,
2006; Cameron & Keenan, 2013; Norcross, 2002; Wampold, 2010). As such, to ignore
this aspect of our work is to ignore a critical tool in the work we do with our clients.
The processing of the bond can be emotional for both you and your client. As stated
previously in this chapter, termination can bring up a number of emotions for all parties
involved. Discussing the connection that was formed between you and your clients may
be difficult, for each of you, depending on your respective comfort levels with emotions. It
is important to keep in mind that the reactions of your clients to processing the emotional
bond are influenced by many factors, including their culture (Conner & Grote, 2008;
Fontes & Plummer, 2010; Zayas, Torres, & Cabassa, 2009), as well as the power differential
that exists between you and your clients (Ow & Katz, 1999; Xiong, Tuicomepee, LaBlanc,
& Rainey, 2006). The emotions they experience may also be connected to their past losses.
You may also have strong feelings about your client, positive or negative. These feel-
ings should first be processed with your supervisor, and together you can decide on what
is appropriate to share with your client and what is not. Remember that the work you do

154 • Moving Beyond Assessment

with your clients is always in the service of your client, not you. While it is important to
be authentic with your clients, your needs are not to be met here and should be addressed
outside the work with the clients.

BOUNDARIES AND TERMINATION

It is at the boundary and termination times when there is the potential for social workers
to cross boundaries or violate one of our professions ethics. These violations are almost
always unplanned and started with the best intentions, most often due to not wanting to
abandon the client or wanting the client feel that the worker still cares. These intentions
can turn into dual relationships or promises made that are outside the scope of the relation-
ship. Workers might also at this time feel that sharing personal information, such as a social
media or e-​mail account, a cell phone number, or some other personal information, is a way
to “stay in touch.” We caution you strongly to avoid this temptation. Ask yourself, “Whose
needs am I meeting by providing such information?” Discuss each of these potential deci-
sions with a senior colleague or your supervisor before offering any such information. Your
job is to protect the client, and it is essential that you use your self-​awareness and supervi-
sion to ensure that every decision you make is consistent with that responsibility.
There is often debate about how long a former client is to be considered a client. How
long after ending a professional working relationship is it okay to transition to a different
kind of relationship? Our Code of Ethics does not concretely answer this question, so it is
up to you to think about agency policy and your own boundaries to make a determination
about this. Think carefully about how to handle requests years down the road.
We take a blanket stance on this issue, with the feeling of “once a client, always a cli-
ent.” This comes from many years of working in the same agency and then the same city
providing counseling services in the community. I (E.D.) recall a time when a former cli-
ent contacted me to let me know she had graduated from her professional school. Working
on her own self-​doubt and barriers to success in school had been part of what she explored
in our work. She was proud and wanted to share this news with me. After a brief chat
in which I congratulated her on this tremendous achievement, she asked if we could get
together for coffee. I let her know that I could not do that. I explained that I believe it is
important to always remain in our professional roles in the event that she ever needs ser-
vices from me at some point in the future. When I asked how she felt about that, she said
she was disappointed, but understood. A few months later, I heard from her again; this
time she was asking to come back for counseling. In our meeting, she said she realized that
what she really wanted was to come back for more services, but did not want to admit to
me, or herself, that she still had more work to do. Each practitioner needs to come to his or
her own position on this, but it should be consistent across clients and over time.

RITUALS/​C ELEBRATIONS
There are many ways to celebrate the ending of the work you and your client have done.
Some rituals are built in to a program, such as a graduation from a school or group home.

Endings • 155
These rituals can be done on an individual basis, or they can be conducted for an entire
cohort that may have started and have ended together.
If there is not a built-​in form of celebration, many social workers have found that using
rituals is a powerful and meaningful way to end the service with a client (Hepworth,
Rooney, Dewberry-​Rooney, & Strom-​Gottfried, 2013; Miley et al., 2013). As with all
aspects we have discussed so far, it is essential to discuss ideas with supervisors regarding
the appropriateness of any celebration. The ritual on which you and your client agree must
be consistent with the culture and mission of your agency. In addition, it is important to
ask your clients how they would like to mark the ending of the work. It may be that they
would not like to do anything, and those wishes should be respected.
Celebrating the ending of your work with clients can be a time to be creative but
should always be based on the needs and wishes of the client. You can also use activities or
certain tasks to help clients keep the date of your final meeting in mind. The following is a
list of the rituals that we have used in our own clinical work:

• Calendars—​These can be photocopied or downloaded. On the calendar, the dates

of each meeting can be marked to keep track of the remaining meetings.
• Braid or rope—​Children especially can have a difficult time with time. Rather
than a calendar, which might be too abstract, you and your client can create a braid
or rope and tie knots in the rope that represent the remaining number of meetings.
At the end of each meeting, the knots can be cut off and placed in a container of
some sort.
• Transitional object—​Psychodynamic theory discusses the idea of a transitional
object (see Applegate & Bonovitz, 1995, for more information on this concept).
The idea of a transitional object is that it is an item that helps the individual
remember the person who is associated with comfort even when that person
is not physically present. Clients can take a transitional object with them
from the end of the work together. It can be a termination letter you write
them summarizing their accomplishments, a business card in case they have
questions after the end of the work, or some other object from your office. I
(E.D.) used to have a Zen garden in my office that clients could use. I would put
stones and seashells in the sand. At termination, I would allow clients to take
an item from the Zen garden with them if they wished. I (M.D.G.) have had
clients take with them an item from my sand tray collection that represented a
particular part of the work together to remember the work that they did with
me. Clients may also choose to leave a transitional object with you, such as a
handmade card of thanks or other object that has meaning. Transitional objects
can often fall under the category of gifts, which we discuss more fully in the
next section.
• Discharge summary—​It can often be difficult for clients to internalize or
remember all of the feedback or sharing that takes place during the last few
meetings. One option is to write and give the client his or her own “discharge
summary” that provides an overview of where they were at the start of your work
together and all that he or she had accomplished. It can also serve as a platform
to highlight and emphasize the client’s strengths, as well as record any relapse

156 • Moving Beyond Assessment

 prevention actions or follow-​up supports that you have discussed. It is a document
that the client can take and review as many times as desired.

GIFTS
Often associated with endings and celebrations or graduations are gifts. We have discussed
gifts previously; however, it is worth repeating that it is important to ask your supervisor
about the agency’s gift policy and to be prepared to respond if a client gives you a gift
so that you can act consistently with the agency’s policy. It can be helpful to think this
through in supervision and even role-​play what you want to say. We do not believe that
there is a right or a wrong answer to the idea of giving or receiving gifts. These decisions
should be based on the individuals with whom you are working and in consideration of
the agency’s culture and policies. As with sharing information, if you wish to give a gift to
a client, it is important to discuss this wish with your supervisor and the appropriateness
of such a gift, regardless of how small or inconsequential you believe such a gift might be.

KEY POINTS TO REMEMBER

FOR TERMINATION
• You can help clients by identifying their past patterns and help them to plan for a
different kind of ending.
• Preparation here can go a long way.
• Plan for termination during the first session, as your role is to help clients to be
independent and empower them to succeed on their own.
• You and your clients will both have feelings about the ending:
• It is important to be self-​aware.
• Anticipate for both of you what might be triggered.
• Use supervision and consultation.
• Rituals can help celebrate and aid in the transition.
• Be careful of potential boundary and ethical issues.

Endings • 157
 CHAPTER 15

EVALUATION OF PRACTICE

I magine you were going to be taking a course of some kind where you are
hoping to improve your skills or knowledge in some area. It could be anything, such as an
academic course, a cooking class, or an exercise class. You are paying for the course and
going to all of the sessions, as well as doing whatever extra tasks are required outside the
class time. Hopefully you are taking the course by choice, but even if you are not, imagine
where you might be in terms of your skills or knowledge at the start of this imaginary
course. By the end of it, you certainly would want to see that you had improved and gained
something. Yet, how will you know if all that time and energy made a difference? If it is
an academic course, you often receive a grade that may or may not reflect your knowledge
and effort. If is not an academic course, such as a cooking course, how will you know that
you are a better cook than when you started? On what basis will you make this judgment?
Who will decide whether there has been improvement and based on what standard? Is
it that you want to be better in learning how to cook a certain type of food, or are you
more interested in knowing more about the chemistry of cooking and how ingredients fit
together in general?
These are the same types of questions that you and your clients should be asking as
you think about working together on their goals. Clients will come to you in hopes that
something will change. It could be that they want to find safe housing or to have a better
ability to manage their depressive symptoms to become more socially connected in their
communities. Some of these desired changes or goals might have obvious benchmarks,
such as finding safe housing. Yet, what does safe housing mean, particularly to the client?
Does becoming more socially connected in the community mean having two acquain-
tances, or does it mean attending a community group once per month? As we discussed
in Chapter 13 on treatment planning, it is critical that you and your client identify how
you will both know when the changes that they are seeking have happened. By identify-
ing these outcomes or objectives in the treatment-​planning stage of the work with clients,
you have done a bulk of the work in evaluating your practice, especially when it comes to
termination.
In addition to deciding when to terminate work with clients as discussed in Chapter 14,
it is critical that social workers conduct ongoing evaluations with clients to know whether
the work together is heading in the right direction. Returning to the cooking class
example, think about how it would feel to reach the end of the class and realize that you
had not improved in your cooking. Now, think about how you would feel in the scenario
where you discovered early in the course that you were not improving. Immediately, your
instructor made an adjustment in his or her teaching to help you to make improvements
in your cooking. Which experience would you rather have? Hopefully the latter one! If
we are working with clients and we are not seeing that our work together is helping them
get closer to their goals, then we need to step back and look carefully at what we are doing
and find ways to shift the work so that it is more effective. Not only is this act a practical
and common-​sense response, but also it is identified by the National Association of Social
Workers’ (NASW, 2008) Code of Ethics as part of ethical practice. “Social workers should
monitor and evaluate policies, the implementation of programs, and practice interven-
tions” (Section 5.02.a). This chapter provides some easy-​to-​use tools in your work with
clients to help you and your client determine when the goals have been met. We also intro-
duce some ongoing evaluation tools that can be used to help you and your clients ensure
that you are working effectively toward their goals.

METHODS FOR EVALUATING

GOAL ACHIEVEMENT
According to Gambrill (2013), there are “10 Ways to Fool Yourself and Your Clients
About Degree of Progress” (Table 15.1)So you do not fall into these traps, it is important
to think about methods of evaluating the progress clients are making by keeping in mind
the guidelines shown in Table 15.2 that we created to address Gambrill’s list. We expand
on these ideas in the chapter, but they serve as a quick checklist for you as you think about
beginning your work with a client. Remember that the bulk of the work on how to evalu-
ate your work with a client starts at the beginning.
The rest of this chapter highlights and elaborates on some of the major themes from
this list.

TABLE 15.1: What Not to Do in Evaluating Progress

10 Ways to Fool Yourself and Your Clients About Degree of Progress

1. Focus on vague outcomes
2. Rely on testimonials
3. Rely on your intuition
4. Select measures that are easy to use even though they are not related
to the intended outcome
5. Do not gather baseline data
6. Assess progress only in artificial settings, such as the office
7. Under no circumstances graph the data
8. Use only pre-​/​post-​test measures (do not check in during the middle)
9. Use only postmeasures
10. Do not gather follow-​up data (Gabmrill 2013, p. 491)

Evaluation of Practice • 159

TABLE 15.2: Evaluation Guidelines

Guidelines for Evaluating Progress Toward Goals

1. Be specific regarding your goals and your objectives (remember SMART (specific,
measurable, achievable, relevant, and with a time frame) goals from Chapter 12?)
2. Use measures to be completed by your client that include objective indicators that can
also be paired with subjective measures.
3. Actually use evaluation tools rather than using your own ideas about how the work is
going.
4. Ensure that the measures you use are relevant to the client’s issues and needs.
5. Be specific with your client at the beginning of treatment about where they are in their
work toward the goal—​what is their baseline now?
6. Assess how the client is doing outside the setting in which you and the client work.
Think about how to look at the progress of the goal(s) in multiple settings (i.e., within
the foster home, at school, at the job site, with other residents in a shelter).
7. Use visual depictions of the progress. Graphs provide an easy method to measure
progress on a goal.
8. Track the progress you and your client are making throughout your time with the client.
9. Use pre-​and postmeasures, as well as continuous assessment tools.
10. When possible, gather information from your clients after the work has been completed.
These time frames could range from 1 month to 2 years or beyond.

BE SPECIFIC WITH GOALS AND OBJECTIVES

As we emphasized in Chapter 13 on goal setting and in Chapter 14 on endings, there is
a strong connection between treatment planning and termination. The clearer you and
your client can be about where the client wants to be at the end of your work together, the
easier it is to evaluate whether the client has met those goals. Of course, goals can change
throughout treatment. Yet, we strongly recommend that with each new or altered goal,
you put in the time to create that goal so it is clear what the intended outcomes will be at
the end. Returning to the cooking class example, the more you are clear at the beginning
of the course about what you hope to achieve, the more you will know about whether you
have achieved your goal by the end.

USE A COMBINATION OF OBJECTIVE

AND SUBJECTIVE MEASURES
It is critical that social workers use measurement strategies to assess the progress that cli-
ents are making in the work you are doing together. There are two main types of measures
that are used in evaluating practice: objective and subjective. There are pros and cons
to each approach, which is why advocate a combination of both for your work. Objective
measures are not based on your own or your client’s biases or opinions. These measures
use concepts that evaluate an outcome based on a set standard. Examples of objective
measures are a change in score on a standardized symptom checklist, the number of social

160 • Moving Beyond Assessment

contacts an assisted living resident has had in the last 3 weeks, the number of fights in
school in a month, or the number of temper tantrums a 2-​year-​old has during a week.
Each of these measures is not tied to anyone’s perception so they indicate how the client
has made shifts. These measures in theory are outside the bias of the client or the social
worker.
Subjective measures are those that ask either the client or the social worker (or in some
instances a third party, such as a parent or guardian) about their perceptions of the prog-
ress or changes that the client has made during the work. These measures ask different
parties to share their opinions about any perceived changes and do not use an external
method to gauge progress. Examples of subjective measures include a self-​rating scale
regarding anxiety levels, a social worker’s assessment of the working alliance, or a parent’s
perception about what has contributed to their child’s mood shifts. While these pieces of
information help inform both the client and the worker regarding how they believe the
work is progressing and what they believe has been helpful or not helpful so far, they do
not provide an unbiased view of the progress to date.
We believe that both types of data are useful to social workers and should be included
in the work with clients. What we want to emphasize here is that social workers need to
do something to measure progress. Our Code of Ethics (NASW, 2008) requires it, and we
believe it is simply good practice to ensure that the work with your client remains useful
in helping him or her to reach personal goals.
Next, we provide brief summaries of different ways to include measures, both objec-
tive and subjective, that can be easily incorporated into your work with clients. These are
easy to use, and we encourage readers to learn more about them from research textbooks
and other similar resources that we have listed in the in the summary guide at the end of
the chapter.

OBJECTIVE MEASURES
Standardized Instruments: One of the most common objective methods used to eliminate
bias is to use standardized instruments. These instruments are measures that

have uniform procedures for administration and scoring and are accompanied
by certain kinds of information, including data concerning reliability, validity,
and norms (average scores of certain groups). Standardized measures are used
to: (1) describe populations or clients; (2) screen clients (e.g. make a decision about
the need for further assessment or find out if a client is eligible for or likely to require
a service); (3) assess clients (a more detailed review); (4) evaluate progress; and
(5) make predictions about the likely futures of clients. (Gambrill, 2013, p. 395)

Given the number of ways that these measures are used, there are thousands of instru-
ments that have been designed for countless settings, populations, symptoms, ages, lan-
guages, cultures, and other topics. Many of these instruments can be found online for
free and with easily accessible instructions; others either require specialized training or
are restricted by copyright laws. Therefore, it is important that you check first what the

Evaluation of Practice • 161

TABLE 15.3: Standardized Instruments

Pros Cons
Gather specific information about a client Narrow in scope regarding what is assessed
Efficient methods of gathering information May not be applicable or appropriate for your
about a client or clients and not client(s) as the tests may not have been tested
dependent on the social worker’s or evaluated using clients similar to yours
memory regarding what to ask
Have in theory been tested and evaluated Person administering them may not be adequately
for being unbiased and objective trained to obtain accurate information or to
interpret the information correctly
Provide a succinct picture of an aspect of Do not start where the client is; rather bring an
the client’s life (e.g., level of functioning, external focus regarding the issues
amount of social supports)
Help to normalize for the client some of Often instruments that are designed to
their struggles as they see that others understand children and adolescents ask the
have had similar ones adults for their feedback and not the child
Can provide a launching pad for more in-​ Often do not assess for strengths but rather
depth discussions of their struggles assess for deficits
Provide clients with information to help Could bias the social worker about a particular
them link to additional information that client based on how the client “scores” on the
may help them understand the struggles instrument
Help to put their struggles in perspective Language used or questions included may be
compared to other individuals who are biased
like them

restrictions are for any instrument you are interested in using. In addition, it is essential
that you fully inform your clients of any risks or benefits, as well as how the instrument
will be used and who will have access to it.
Depending on your setting, you may use such instruments for all or only one or two of
the categories described previously. While there are many benefits to using standardized
instruments, we would like to caution you also to consider some of the risks. “Many tests,
for example, have biases, low reliability and poor validity; some are ill suited for certain
clients and thus should be used with extreme caution” (Hepworth et al., 2013, p. 191). We
listed in Table 15.3 some of the benefits as well as the cons as summarized by Grady and
Drisko (2014).
We feel that Gambrill’s (2013, p. 397) “Checklist for Reviewing Standardized
Measures” is useful for new social workers who are starting to use these instruments
(Table 15.4). We also want to add that many standardized instruments do in fact depend
on subjective data. In other words, instruments that have been standardized on differ-
ent populations rely on the client’s report of how he or she is feeling, thinking, or behav-
ing. It is therefore important to keep in mind that not all standardized instruments are
completely objective. However, they are designed to take much of the bias out of client
self-​report.
For those who are interested in finding standardized measures that might be useful for
their work, there are two primary resources that we recommend. The first is the database

162 • Moving Beyond Assessment

TABLE 15.4: Standardized Instrument Checklist

Checklist for Reviewing Standardized Measures

1. Data are available showing that the measure is valid (measures what it is supposed to
measure).
2. Data are useful in understanding client concerns.
3. Test-​retest reliability (you can give in to someone twice in a short amount of time and get
similar results) is high (in the absence of real change).
4. Easy to complete and does not take much time.
5. Acceptable to clients.
6. Required readings levels match client’s skills.
7. Sensitive (small changes can be detected).
8. The user has the knowledge required to make effective use of the measure.
9. Norms are available for the populations of concerns (your client’s demographics can be
compared to others similar to him or her).
10. Data concerning reactive effects (clients are more likely to answer a particular way
on subsequent administrations of the instrument based on their pre-​test scores) are
available.
11. Responses are quantifiable (you can count them).
12. The false positive is low (clients are incorrectly assumed to have a certain characteristic)
13. The false negative is low (clients are incorrectly assumed to NOT have a certain
characteristic).
14. Biases are minimal (e.g. there is a way to tell if clients are just telling you what you want to
hear).
15. Instructions for administration, scoring, and interpretation are clear
16. Cultural differences are considered in relation to content

Note: Adapted from Social work practice: A critical thinker’s guide (3rd ed.), by E. Gambrill, Oxford
University Press, p. 397.

Health and Psychological Instruments (HAPI), which is available through many school
libraries. It has a long list of available instruments and important information about them,
such as related studies on their strengths, appropriate populations, and scholarly articles
that report on the use of the instrument in research and practice. Another key source is
by Fischer and Corcoran (2013a, 2013b). This two-​volume set includes numerous instru-
ments with similar information as can be found in HAPI, but also often provides the com-
plete instrument. The volumes are separated by developmental stages and outline those
instruments for use with adults, children, adolescents, and families. These volumes are
commonly found in most academic library settings.
Single-​System Designs: Single-​System Designs (SSDs) are also referred to as Single-​
Case Designs as they are an evaluation method used to assess one client system, which
could be that of an individual, family, group, organization, or a community (Bloom,
Fischer, & Orme, 2009). These evaluation methods can be simple as well as complex, with
the more complex designs discussed in research methods courses. Here, we provide an
overview of the basic ideas so that you can see how easily they can be incorporated into
work with clients.
The overall aim of SSDs is to provide objective measures of the changes in the tar-
geted issues over time. They allow you to show data before the start of the intervention,

Evaluation of Practice • 163

or the baseline, as well as during various parts of the intervention phase. As such, most
SSD methods use a simple comparison between the baseline phase and the intervention
phase to monitor any changes for the target issue. In SSD, the baseline phase of the work
is indicated as Point A and the intervention phase is B. This comparison is then referred to
as an AB design. As stated previously, there are more complex designs, but they all follow
the same principles; each phase of the intervention is compared to other phases to see if
there were changes in the desired directions. In this book, we only introduce the idea of
an AB design.
The key to a useful SSD is to identify the most helpful outcome for that client in light
of the context. One of the key areas that should be considered in deciding on the outcome
is what exactly will be measured. This outcome could be the number of temper tantrums
in a day, the score on a depression inventory, the number of social contacts a person has in
a week, the number of times someone completes a rehabilitation task, or countless other
examples. It is essential that the identified outcome is an accurate representation of the
desired change, which could be an increase or a decrease in a particular event, and that
everyone agrees on the exact definition of what will be “counted” and what will not be.
The more specific regarding what counts that you, your client, and other involved parties
can be in relation to what specifically will be counted, the more accurate and consistent
your evaluation will be.
During the beginning part of the AB planning process, it is also important to identify
the end goal. In other words, how will you and your client know that you have reached
your goal? If someone has a pattern of 10 temper tantrums per day, is the goal to have zero?
Or, is the goal to have 3 each week total? Is the goal to change the frequency of the temper
tantrums, the intensity, or the duration? How you measure the targeted goal is directly
related to how you will know if you have reached that goal.
Another important consideration is a realistic time frame for what is being measured.
In other words, if the focus of the work is on something that occurs every day, such as a
temper tantrum, then the measure should be one that accurately measures the daily or
maybe even hourly rate of temper tantrums. However, if the goal of the work is to help
someone increase their social contacts over the course of a week or a month, then the
measure needs to reflect this time frame for the goal.
It is also important in the design of such a system for social workers to address the
ease with which the event can be measured. For example, teachers who have 30 children
in a classroom cannot easily fill out a behavioral chart every 15 minutes for 1 of these 30
students. So, while it may be helpful for the social worker to have a picture of each 15-​
minute increment during the day to see a detailed pattern, it is not realistic to expect the
teacher to accurately record a child’s behavior given the other demands in the classroom.
Therefore, you must choose measurement strategies that are easy to execute and realistic
given the context of the clients’ lives.
Once you have considered all of these factors, the actual measurement begins. During
the baseline and intervention phases, the same outcome measure should be used so that
a clear comparison can be made between the various phases. The length of each phase
is dependent on the issue and what is being measured. If the goal is to increase social
interactions each week, then there is a shorter time frame to obtain more measures for
that outcome, as compared to a monthly count. A daily count provides more points in

164 • Moving Beyond Assessment

time than weekly or monthly, but it may show only a “good week” and may not depict
actual long-​term trends. Therefore, it is important that social workers think through what
is the most appropriate length of time to measure the outcome given what the goals of the
intervention are.
Ideally, the baseline phase should be continued until “the pattern of behavior is fairly
clear” (Gambrill, 2013, p. 501). While it is always ideal to have a “real-​time” baseline,
where clients begin to record the issue, if it is a long time frame (i.e., a month), it is possi-
ble to retroactively record the baseline by estimating. Again, this method is not ideal but
may be necessary in some settings or situations. One example of such a situation is the
number of hospitalizations an individual has had over the last 6 months. In this case, the
client’s records can be used to establish a baseline rather than waiting 6 months to create
a baseline in real time. It is also important to note that some clients may begin to change
the frequency of the issue simply due to recording it. These trends should also be recorded
and included in the baseline counts.
The AB design allows you and the client to numerically and pictorially see if there
have been any changes since the baseline phase began. Graphing changes is a wonder-
ful way for you and your client to actually visualize the changes that are being made
(Bloom et al., 2009; Engel & Schutt, 2014; Gambrill; 2013). Graphing can be done by
hand, using a word-​processing software program, or using a program like Excel that
will make the graph for you. The graphs are set up to have the number of events of
interest (i.e., number of temper tantrums or symptoms on a checklist) on the y axis
(the vertical one) and the time on the x axis (the horizontal one). A line is created
down the middle at the point of time when the baseline phase ends and the interven-
tion phase begins. Figure 15.1 is an example of a graph of an SSD with an AB design
for an individual who has been getting in fights at the homeless shelter where the indi-
vidual is staying.
The graph in Figure 15.1 allows the social worker and the client to see if there is prog-
ress toward the goal. However, it is important that the worker and the client determine
whether those changes are meaningful to the client. In other words, even if the shift is
Number of fights per week

10

1 5 10 15
Weeks
A B
Baseline Intervention

FIGURE 15.1: Single-​system design graph.

Evaluation of Practice • 165

going in the right direction, is it enough? Is it sustaining? The social worker and client will
need to determine when they have reached the point in the work together at which the
marks on the graph represent a meaningful change.
There is much more that could be said here about SSD. You are encouraged to look at
the summary guide for other information on how to use them.

SUBJECTIVE MEASURES
Goal Attainment Scales: Goal Attainment Scales (GASs) are tools that are based on the cli-
ent’s own criteria for assessment, which means that they are individualized for that client’s
particular goals and capacities. Because they are specific to each client’s needs, they are
seen as more subjective measures rather than objective ones. GASs can be used for all “cli-
ent systems (individuals, families, groups, organizations, and communities) to identify
intervention goals and to specify expected outcome levels for each goal” (Miley, O’Melia,
& DuBois, 2013, p. 421). One of the strengths of a GAS is that it focuses exclusively on
stated goals rather than being problem focused, which fits well with social work values and
ethics (NASW, 2008).
These scales are created as a grid or rubric to identify the various levels of goal
achievement. Each level of achievement is given a score, generally ranging from –​2 up to
+2, with –​2 representing “less than expected” and +2 representing “more than expected.”
Each score corresponds to a specific set of outcomes that have been identified by the
social worker along with the client. Table 15.5 is an example of a GAS showing what one
might look like for an individual who is living in an assisted living facility and is socially
isolated.
The advantages of using GASs include how each can be individualized for each par-
ticular client’s needs and context. They can also be used regardless of the size of the client
system and are user friendly (Miley et al., 2013). Some of the disadvantages are that they
are seen as subjective more than objective as they have not been tested for their validity
or reliability as standardized measures have been (Miley et al., 2013). Yet, social workers
may find these measures to be user-​f riendly tools that help the worker and the client iden-
tify concretely where the work is going and how they will know when they have reached
those goals.

TABLE 15.5: Goal Attainment Scale

Level Behavior
–​2 = baseline Does not engage in any social interactions with
friends each week
–​1 = less than expected outcome Engages in 1 social activity/​week
0 = expected outcome Engages in 3 social activities/​week
+1 = Greater than expected Engages in 4 social activities/​week
+2 = M uch greater than expected Engages in 5+ social activities/​week
outcome

166 • Moving Beyond Assessment

 Self-​Anchored Scales: These are scales that are developed by the client and the social
worker to monitor a particular feeling or experience. They are subjective because they use
the client’s words and perceptions both to create the scales and to complete them. Self-​
anchored scales are created by asking the client to think of two extremes of the issue he
or she is facing, such as his or her level of anger. One “anchor” represents the most benign
or mild experience of this issue, and the other anchor represents the highest level. For
example, a 1 might represent least anger and a 10 represent the most anger. It is important
for the terms to be consistent on the two anchors and for the client to help define what a 1
means or looks like for them, as well as a 10 or other midpoints along the scale. Table 15.6
is an example of a 7-​point scale for anger.
Self-​anchored scales can be useful in gathering information for an SSD or for teaching
clients a skill related to self-​monitoring. “Clients can use self-​anchoring scales to record
the extent of troubling internal states across specified time intervals (e.g. three times daily
for seven days) in much the same way that they take frequency counts of overt behaviors”
(Hepworth, Rooney, Dewberry-​Rooney, & Strom-​Gottfried, 2013, p. 359).
Session-​Monitoring Scales: Another way to measure outcomes is to have an ongoing
assessment of the client’s feedback regarding how he or she feels in progressing toward
the selected goals. This attempt to use client feedback in a systematic way is consistent
with practice-​based evidence, which “requires that practitioners adopt a highly individu-
alized service delivery plan for each patient, acknowledging the patient’s goals for treat-
ment, ideas about how change occurs, and view of an effective therapeutic relationship”
(Campbell & Hemsley, 2009, p. 1).
Real-​time monitoring of the progress allows the client and social worker to make
modifications quickly before the work becomes too off track. In addition, studies have
shown that overall client outcomes improve when practitioners use assessment tools to
obtain feedback from the client at the end of each session (Duncan et al., 2003). These
tools assess how well the session addressed the client’s needs, whether the client felt heard,
whether the practitioner addressed the goals the client had for the session, as well as other
areas (Duncan et al., 2003). These instruments can be user-​friendly tools that practi-
tioners can use to improve outcomes with their clients (Bringhurst, Watson, Miller, &
Duncan, 2006; Campbell & Hemsley, 2009; Duncan et al., 2003).
Two of the most commonly used instruments are the Outcome Rating Scale (ORS)
and the Session Rating Scale (SRS; Miller & Duncan, 2000). The ORS is designed to
mainly measure the desired outcomes or level of distress by the presenting problem,
whereas the SRS is designed to measure the alliance between the practitioner and the
client (Campbell & Hemsley, 2009). These instruments have been shown to be valid and

TABLE 15.6: Self-​Anchored Scale

1 2 3 4 5 6 7
Least angry Moderately angry Most angry
(feel calm, relaxed) (feel tension in body, breathing (clenching fists,
is getting faster, but still able to yelling, want to
function) punch a wall)

Evaluation of Practice • 167

reliable with a variety of populations and ages in multiple research studies (Campbell &
Hemsley, 2009). They are very user friendly and take only a few minutes to complete.
Depending on what information the social worker may find to be most useful, he or she
may choose to use one or both of these instruments with clients. In addition, the authors
have made them available to practitioners for free and have provided detailed instruc-
tions on how to use them as well as provided citations for the numerous studies that
have been conducted using them. All of this information can be found online (https://​
heartandsoulofchange.com/​), and multiple resources are provided to help practitioners
improve outcomes.

CHAPTER SUMMARY
In this chapter, we discussed the importance of evaluating the progress the client is mak-
ing toward personal goals. It is not only good practice but also consistent with our profes-
sion’s code of ethics to continuously monitor how effective the services we are providing
are in helping clients reach their goals. Practice evaluation should be viewed as an ongoing
process, not just a task done at the end of the work. This process provides opportunities to
determine if what you are doing is working and to change course if it is not. Returning to
the cooking class example, if you went in hoping to learn how to cook a soufflé and real-
ized at the end you could not do it, you will be disappointed and even angry. If you find out
midway that you are off course, then you can correct that in time for a successful outcome.
We have provided you with a number of user-​f riendly tools to measure outcomes. These
can be easily woven into plans for intervention as well as into conversations with clients
about termination when that time comes.

CHAPTER 15 RESOURCE GUIDE

RESEARCH TEXTBOOK REFERENCES
Bloom, M., Fischer, J., & Orme, J. G. (2009). Evaluating practice: Guidelines for the accountable professional
(6th ed.). Boston, MA: Pearson.
Engel, R. J., & Schutt, R. K. (2013). The practice of research in social work (3rd ed.). Thousand Oaks, CA: Sage.
Lomand, T. C. (2012). Social science research (7th ed.). Glendale, CA: Pyrczak.
Ogles, B. M., Lambert, M. J., & Master, K. S. (1996). Assessing outcome in clinical practice. Boston, MA:
Allyn & Bacon.
Pyrczak, F. (2013). Evaluating research in academic journals: A practical guide to realistic evaluation (6th ed.).
Glendale, CA: Pyrczak.
Sederer, L. I., & Dickey, B. (Eds.). (1996). Outcomes assessment in clinical practice. Baltimore, MD:
Williams & Wilkins.

168 • Moving Beyond Assessment

 PA R T I V

ONGOING ISSUES
FOR CONSIDERATION
 CHAPTER 16

SUPERVISION

W e hope that by now many of you have had the chance to experience
a supervisory relationship that feels supportive as well as educational. We believe that for
new practitioners such a relationship is at the core of learning how to be a professional
social worker. Supervision plays a critical role in shaping one’s developmental trajectory.
As such, we believe it is essential to identify key characteristics of this relationship so that
practitioners maximize the benefits and growth opportunities that can result from such an
experience. Supervision styles differ across fields of practice; therefore, it is essential to find
a good fit between supervisor and supervisee to create a safe professional relationship in
which to grow and develop as a social work practitioner. In some settings, you may not get
to choose your supervisors, which may be because of your assigned internship or because
in a new position someone within the agency is appointed as your supervisor. When you
are unable to choose your own supervisor, there may be a gap between what the supervisee
wants from supervision and the supervisor’s approach. The challenge becomes identifying
and using the strengths of this relationship to maximize the learning potential.
This chapter explores how new practitioners can use supervision as part of their learn-
ing experience, how to use supervisor feedback in the learning process, and the nuts and
bolts of supervision. We highlight the differences between one’s own therapy for personal
growth and the supervisory relationship for professional learning and the importance of
keeping these relationships separate.
We strongly recommend that as you review each of the sections of this chapter, you
reflect on what your supervisory experiences have been to date. Think about how these
experiences compare to some of our advice, what you appreciated about those relation-
ships, what you felt was lacking, and what you would wish for in the next experience or
even a current one. If you are the supervisee, the supervision experience is really about
you. The more you can identify what you want and need in this relationship, the more
easily you will be able to articulate these wishes and have your learning needs met.

NUTS AND BOLTS OF SUPERVISION

There are many factors that have an impact on how supervisors provide supervision. The
setting, the type of work that the practitioner will be doing, as well as the personal style
of the supervisor will all influence how the supervisor delivers supervision. However,
unlike what is often the case in a classroom or group setting where you “get what you get,”
in supervision, there are some norms and some legal requirements that can play a role
in what the supervisor provides on a basic level, as well as other nuts and bolts that you
should consider as the supervisee. You are your best advocate to get your needs met, so we
encourage you to be clear about what you need and want.

LENGTH OF TIME OF SUPERVISION

The length of time and the frequency of supervision meetings vary depending primarily
on the needs of the supervisee. In an internship setting, ideally supervision is held weekly,
at a set time and place that is consistent from week to week, for 50 minutes to an hour. If
an individual who has just graduated with his master’s degree in social work (MSW) is
hoping to obtain a clinical license, most jurisdictions require that the new MSW graduate
receive an average of 1 hour of supervision per 40-​hour work week. These meetings must
be documented and then recorded and submitted to the jurisdiction where the supervisee
is working to obtain a license. Most jurisdictions require about 2 years of supervision as
part of the licensing requirements, which ends up being about 100 hours total (50 hours/​
year for 2 years). However, this number varies, and it is the supervisee’s responsibility to
know the requirements for wherever jurisdiction he or she is seeking licensure.

CREATING PROTECTED TIME

During supervision, both the supervisor and the supervisee should protect this time together.
Protected time means that the meeting remains free from interruptions or distractions, and
the supervisee has the supervisor’s full attention. Unfortunately, many practitioners do not
work in settings where the time feels protected. In these cases, supervision can often feel like
it is being held “on the fly” or “catch-​as-​catch-​can.” Hallway check-​ins, e-​mail follow-​ups, and
brief meetings to discuss pressing matters are often provided in the place of regular supervi-
sion meetings in settings where finding a sacred 50-​to 60-​minute block of time is difficult.
When at all possible, we suggest that the supervisee request the following to increase
the likelihood that the supervision time will be protected:

• Schedule the meeting for the same block of time each week. A regular time
increases the likelihood that the time will be embedded in each person’s schedule
and will become more of a habit as a result.
• Request that phone calls, e-​mail notifications, and other electronic interruptions
be eliminated or reduced by turning off phones or computer notifications.
• Identify a quiet location, which may or may not be a personal office. It is important
to be in a space that not only is not in the flow of the daily activities of the agency
whenever possible but also allows for discussion of confidential material.
• Use a “do not disturb” sign if you are meeting in a room to reduce the number of
interruptions during your meeting.

172 • Moving Beyond Assessment

As stated previously, you are your best advocate to have your needs met in supervision.
These logistical factors can play a significant role in accomplishing such a goal.

PURPOSES AND TASKS OF SUPERVISION

According to the National Association of Social Workers (NASW) and Association of
Social Work Boards (ASWB) (2013), the three main tasks of social work supervision are
addressing administrative tasks, overseeing client casework and attending to the educa-
tion of new workers, and supporting the supervisee in his or her work. The first addresses
administrative issues and tracks the worker’s progress on paperwork, monitoring pro-
ductivity, and addressing policies and procedures to ensure they are being followed. To
address this, the supervisor will typically ask the supervisee how many clients he or she
saw last week, whether all the required paperwork is complete, and questions about meet-
ing funding requirements for the program (NASW & ASWB, 2013).
The second task of supervision is to address issues that arise in work with clients. These
discussions are focused on particular clients or specific interactions with clients, and the
supervisee looks for guidance and direction from the supervisor. The focus in these dis-
cussions is educational, as the two individuals discuss how to apply clinical theory, skills,
and interventions with clients, and in doing so attempt to address any gaps in knowledge
that may exist. In addition, during these conversations the supervisor may be assessing
the practitioner’s social work knowledge, skills, and abilities (NASW & ASWB, 2013).
The educational focus in supervision must be handled with care and empathy for the
novice worker to avoid the supervisee feeling judged or criticized. The supervisor’s role
here is to help identify supports to fill in gaps in knowledge or skills and is a critical part
of the supervisor’s role and responsibility as a supervisor. It is the job of the supervisor
to assist in providing feedback on areas where the worker excels, as well as identify areas
for improvement. By providing such feedback, the practitioner can gain important infor-
mation for his or her own professional development. In addition, the supervisor has a
responsibility to the clients served by the supervisee. With this responsibility in mind,
it is essential that the supervisor identify any areas in need of improvement to create bet-
ter outcomes for the clients. The supervisor is ultimately responsible for the work of the
supervisee and thus needs to ensure that the strongest and safest services are provided to
the client. Giving the supervisee feedback on ways to improve his or her work is import-
ant not only for the individual supervisee’s development as a practitioner but also for the
clients served by the agency. To address any gaps, the supervisor may recommend that
the supervisee attend particular trainings or spend time with that supervisee to reinforce
knowledge and skills that need strengthening.
The final, and some might argue most essential, task of supervision is support. When
social work practitioners feel that their supervisors are empathic and encouraging and
want them to learn, grow, and be successful, supervisees reported decreased job-​related
stress and increased confidence (Davis, 2010). In many ways, the provision of supervision
demonstrates an investment in the novice practitioner’s development of a professional
self. It is a commitment to the growth and development of that person for the good of both

Supervision • 173
the individual’s clients and his or her career. This relationship is a crucial one in this early
stage of development and is strengthened when there is trust, support, and solid guidance
during a vulnerable professional time (Bennett & Deal, 2009).

DIFFERENT SUPERVISION FORMATS

As discussed, during a social worker’s training in school and in many settings after grad-
uation, interns and new graduates must be supervised in their agencies. For recent grad-
uates, this requirement is especially true for those who are providing direct practice or
clinical services to clients. However, once someone is licensed, there are no requirements
for supervision to continue. Yet, in our experience many practitioners opt to continue to
have supervision beyond their license for a number of reasons:

• Continued supervision continues the learning process.

• Ethically, it is important to have another set of “eyes” on their work.
• It provides continued experiences of collegiality with other professionals.
• There may be a time in life (e.g., pregnancy, leaving a practice, personal or family
illness) when the practitioner believes that due to their own personal situation,
they may not trust their own judgment as strongly as they have outside the current
circumstances.

Ongoing supervision can utilize many formats. Some practitioners continue with
individual supervision. They may receive supervision for free in their job or see another
practitioner outside their agency at their own expense. Some practitioners prefer to see
someone outside their agency as they have more freedom to be imperfect because the
outside supervisor is not involved in performance reviews that can be tied to merit pay
increases or other performance-​based interests. In addition, sometimes practitioners seek
an outside supervisor because they have an interest in a particular population or topic
area and want to learn from an expert with that body of knowledge. Finally, others seek
outside supervision because no social worker is employed by the agency, and they want to
see a social worker specifically for supervision, even beyond the licensing requirements.
An advantage of individual supervision is that the supervisee is able to receive one-​on-​
one attention and training. The focus of the supervision is driven by the individual’s spe-
cific interests and needs. In addition, the supervisee might feel less vulnerable sharing some
“mess ups” or concerns about his or her work with one person versus a group of colleagues.
A significant disadvantage is the potential cost of individual supervision if it occurs outside
the agency. However, most supervisors offer reduced fees, especially to new practitioners.
Do not be afraid to ask for fee reductions if you are interested in this format. Another disad-
vantage for individual supervision is the flip side of one of the strengths. By having the focus
on him-​or herself, the practitioner does not have the advantage of learning from peers who
may have different perspectives from the supervisor, limiting the views or ideas discussed.
If you choose to seek outside supervision, we strongly recommend that you dis-
cuss this option with your assigned agency supervisor, even if that individual provides
purely administrative supervision (vs. clinical). In our own practices, when we provide

174 • Moving Beyond Assessment

supervision for someone who works at a different agency, we require a signed contract
between the supervisee, the agency supervisor, and ourselves, partly to ensure transpar-
ency among all parties. In the contract, we are also explicit that the agency-​based super-
visor is ultimately responsible for all of the client care, and that all client-​related ideas that
are developed within our supervision need to be discussed and approved by the agency-​
based supervisor, as the supervisor is ultimately responsible for the care and safety of the
clients served by that agency.
In addition to individual supervision, an option is group or peer supervision. Group
supervision is when several practitioners meet together and hire someone to serve as the
supervisor/​consultant. Group supervision can be a great option for newer practitioners as
it can reduce costs because the group members split the costs of the supervisor’s time. In
addition, group supervision allows practitioners to learn from their peers. A significant
disadvantage of this format is that, depending on how often the group meets and how
many members there are, each individual’s time on his own work is limited as the time is
shared among the group members.
Peer supervision is another form of group supervision but generally does not involve
an outside “expert” or supervisor. Rather, the individuals serve as each other’s super-
visors. Peer supervision can occur between people within the same agency or among
people who work in different settings and contexts. One of the advantages of this format
is that it is free. In addition, as each member is considered an equal, there is no hierarchy
within the group. Because of the equal status, peer supervision can provide an import-
ant source of support, which has shown to be essential in decreasing burnout among
practitioners (Kim, Ji, & Kao, 2011). One of the most commonly noted disadvantages
that we have both experienced and heard about from other colleagues is that the groups
can feel like “the blind leading the blind” as there is no one person who is the expert.
Another disadvantage is similar to group supervision: Individual members share the
space and time among their colleagues, limiting the focus on their own work.

MAXIMIZING THE LEARNING OPPORTUNITIES

IN SUPERVISION
While there may be many variables in the supervisory relationship that are out of your
control, there are some ways that you can optimize your own learning in this relationship.
As we stated previously, you need to be your own advocate for getting what you want out
of supervision. The more you are prepared for this relationship, the more satisfied you will
be with how well it meets your expectations and professional goals.

IDENTIFY YOUR OWN LEARNING GOALS AND STYLE

One of the most effective strategies to get what you want out of the supervisory relation-
ship is first to identify what your own learning goals are as well as your learning style. As

Supervision • 175
supervisors, we can tell you that it is much easier to tailor our own style to the needs of our
supervisees when they share with us how we can best meet their needs. We have found,
for example, some supervisees prefer a much more formal or didactic/​classroom teaching
style of supervision, while others prefer to use their own cases as the main topic, with
other information woven into the conversation. Other supervisees would like us to share
articles or book chapters we feel might be relevant or useful, while others are burned out
on academic-​l ike materials. The following are some questions that might help you identify
what it is that you want out of supervision:

• What is your learning style?

• What do you want to learn?
• Where are your gaps in training and experience?
• What style do you want? Didactic, process oriented, or mix?

TYPES OF QUESTIONS TO ASK IN SUPERVISION

In addition to asking yourself questions, another way to improve your odds at getting what
you need in supervision is to be proactive and ask your supervisor questions. When there
is an opportunity to choose a supervisor, you can gain a lot of information by asking a few
pointed questions. First and foremost, it is essential to ask if the professional has the appro-
priate licensure and other qualifications for providing supervision. Many jurisdictions have
requirements related to years of practice experience, completion of supervision coursework
or trainings, and a process of becoming certified by the state board. Many of these states
maintain databases that list the professionals they certify as meeting these requirements. We
strongly recommend that supervisees determine their jurisdictions’ requirements and con-
firm the credentials of any potential supervisor before beginning a supervisory relationship.
For practitioners who are being supervised to earn their own independent clinical
license, it is crucial to ensure that the supervisor is appropriately licensed; those hours of
practice will not count otherwise. You may want to use a conversational style to ask how
long the person has been providing supervision, how and why they got started, how many
people they supervise, and what kind of training and support they receive as a supervisor.
It is also helpful to inquire about the type of practice they conduct. What are the types
of clients and presenting problems with which they work? What theories and models of
practice guide their interventions? Their answers to these questions should line up with
your interests and needs for supervision. Here are some examples of potential questions:

• What is your supervision style?

• What is your fee? Do you have a sliding scale or reduced-​fee time slot?
• What theories guide your work?
• How much do you incorporate the following into supervision:
• Countertransference?
• Diagnosis?
• Theory?
• Culture?
• Or whatever your areas of interest are.

176 • Moving Beyond Assessment

 Even if you are not able to choose your own supervisor, it is important for supervis-
ees to ask supervisors questions about how they approach supervision. Also, supervisees
should inquire about their expectations of you as a supervisee. Once it is clear what the
expectations are for this relationship, we strongly recommend that you and your super-
visor develop a formal agreement or even a contract for how you will conduct supervi-
sion. This contract should also include the goals and tasks for this relationship, which
can be helpful in providing clarity and structure to the meetings. In some jurisdictions,
such a contract is a requirement for the supervision when the social worker is working
toward obtaining a clinical license. For students, many programs require a learning con-
tract between the student, the supervisor, the agency, and the educational program. These
contracts can serve as a useful tool for tracking progress in supervision. In any case, the
question “What are we doing here?” should be explored and answered by both parties.

HOW TO MAKE THE MOST OF A SUPERVISION MEETING

Once the supervisory relationship begins, some practitioners are unsure how to use the
time effectively. Previously, we discussed the three main tasks of the supervisory rela-
tionship: administrational, educational, and support. Keeping these tasks in mind, it is
important to then identify how to address these areas efficiently and walk away feeling
like you have learned from the experience. To increase the likelihood of having such a
feeling, we recommend that supervisees prepare an agenda (see summary guide for a sam-
ple agenda) and think through their questions ahead of time. In preparing your agenda,
it may be helpful to keep in mind the three tasks and organize your questions into those
three categories.
One of the best actions supervisees can take to maximize the learning that can take
place in supervision is to be honest with their supervisors. While it is understandable to
want your supervisor to see the best sides of your work and to provide praise for a job well
done, most of the learning comes from exploring stuck points in your work or processing
mistakes made with clients. Asking questions such as “What am I not seeing here?” and
“How else could I have handled that situation?” are good places to start. You could also
ask your supervisor to guide you toward readings or other resources on situations your
clients are dealing with and interventions you would like to explore. It is often helpful to
ask, “Where should I start in the next session?” This question can be particularly helpful
in the early stages of working with a client and can help guide discussions on assessment,
treatment planning, goal setting, and the beginning stages of the work. It is only through
being honest about what you know and what you do not know that you will truly take
advantage of all that supervision can offer.

BEING VULNERABLE AND RECEIVING

FEEDBACK
We fully recognize that when supervisees ask for feedback and identify the areas where
they are less confident in their knowledge or skills, they are placing themselves in a

Supervision • 177
vulnerable position. It is for this reason that we return to the importance of creating a
relationship that feels safe in order to reflect honestly on yourself, your work, and the
client. When supervisees trust their supervisors, they are able to form such safe relation-
ships (Bennett & Deal, 2009). A safe and trusting relationship is one in which the novice
practitioner can discuss his or her reactions to the work (i.e., vicarious trauma), reactions
to clients, and other personal feelings about the work.
In turn, a supervisor should work to provide, support, and empathize, while provid-
ing guidance and professional education, to earn a supervisee’s trust. Yet, sometimes this
guidance and feedback can feel critical and possibly even shaming. For some people, any
sort of feedback from someone in authority can remind them of past occasions when they
had a strong negative reaction. We hope that all supervisors will provide feedback in a
sensitive and supportive manner. However, if you are someone who knows that you are
especially vulnerable to having a strong negative reaction regardless of how gently it was
given, we recommend that you explore this reaction outside the supervision as much as
possible. There are times when you may find that sharing those past experiences with your
supervisor may actually be possible.
In one of my (M.D.G.)own supervisory experiences, I had a supervisor who reminded
me a great deal of someone is my own life who I worked hard to please and never felt
fully successful in achieving that goal. This desire to please concerning academics espe-
cially was helpful in that it pushed me to strive to be successful in school. However, it also
left me with a hyperawareness of any feedback that I perceived as negative, regardless
of how innocuous it was. I was concerned that this interpersonal dynamic would neg-
atively impact my relationship with the supervisor by leading me not to share my own
perceived weaknesses in order to please this person. After much thought, I opted to share
the dynamic I felt and why I felt it was emerging with this individual and asked for sugges-
tions on how we could interact in a way that would allow me to feel more present rather
than withdraw. Thankfully, this individual was receptive to the feedback, and I found that
I could relax and be more forthcoming in our meetings. It is important to note here that
the dynamic I described was fairly unique to this person, rather than to everyone. In other
relationships, I was able to receive feedback without feeling so negatively about myself.
I do not believe these feelings emerged because of the way the feedback was delivered.
Rather, the feelings emerged due to the way I received the feedback based on my own per-
sonal experiences. Our take home from this experience is that it is important to look at
patterns across relationships that make it difficult for you to receive feedback in a produc-
tive way. It is possible that you may find that sharing your own history with certain indi-
viduals can help you maintain a healthy dynamic and relationship with your supervisor.
It may be helpful to remember that not only does your supervisor have a personal
investment in your success, as mentioned previously, but also the supervisor has a legal
responsibility in the supervisory relationship. Unlicensed professionals are practicing
under their supervisor’s license. Your mistakes are their mistakes in the eyes of the law.
Providing quality, ethical treatment to clients is their priority just as much as your pro-
fessional growth and development. If you can remember that the supervisor’s feedback
comes from these dual foci, it can often feel more like professional guidance than personal
criticism.

178 • Moving Beyond Assessment

 Another important point to remember about feedback is that direction and guidance
given in supervision are not merely advice or suggestion. When a supervisor provides
direct feedback about what to do about a particular situation, the supervisee should
implement the feedback given and report back on how it went. When the supervisee is
defensive or reluctant to trust the guidance of the supervisor, such visible defensiveness
can result in a contentious supervisory relationship that is unproductive and not use-
ful, most especially for the client. When you are open to feedback and exploring what
you can learn and how you can grow professionally, supervision is the catalyst toward
great work.
Due to the power imbalance, it is important to acknowledge that the supervisee can
feel powerless to disagree or challenge the supervisor’s recommendations. In this relation-
ship, the supervisor often has a great deal of power over the supervisee’s future. Obviously,
if the supervisee is concerned about the feedback or has some reasons to suspect that the
advice is not in the best interest of the client or the agency, then the supervisee should seek
guidance from another colleague within the agency. However, in our experience these
are rare occurrences. We find more often than not there is a rich and vibrant discussion
between the supervisee and supervisor about different options and potential outcomes
while exploring and dissecting each other’s thoughts. These discussions can be rich learn-
ing experiences and fun.

HOW SUPERVISION IS DIFFERENT

FROM THERAPY
We hope that we have communicated that supervision can be a wonderful opportunity for
professional growth and development. As social workers, we often learn a great deal more
about ourselves in our work with clients than we could have ever imagined. Supervision
is the place to address the fact that you find it hard to work with a client who reminds
you of your sister, but it is not the place to try to resolve this long-​standing filial con-
flict. Supervision is different from your own personal psychotherapy in that practitioners
should only be addressing their personal issues that are directly connected to the work.
Exploring these dynamics with your supervisor should be done from the lens of how to
manage your “stuff” while working on the client’s stuff. You can see how it would be easy
for supervision to devolve into therapy, so it is the responsibility of both parties to ensure
that this boundary is held secure.
Keeping solid boundaries is essential for supervision. You are not friends, but you are
friendly colleagues who often share personal information with each other. Supervision is
not therapy. Rather, supervision is a relationship that serves to improve your work with
clients through the exploration of how to remove barriers and strengthen assets in that
relationship. Sometimes, the barriers originate from you as well as the client. Sometimes,
your own assets are not being utilized effectively in addition to the client’s. Supervision is
the place to explore these dynamics to improve the client’s life.

Supervision • 179
REFLECTIVE SUPERVISION
Due to the fast-​paced environment of many social work settings, receiving supervision
in a sacred 50-​minute hour is difficult to sustain. This results in less time for practi-
tioners to focus on self-​reflection and awareness in the work, as was often done in more
psychodynamic supervision. The standards for best practices in supervision say nothing
about supervision as a place for supervisees to reflect on themselves in the work and gain
insight into why they are engaging a client in a certain way or approaching a commu-
nity project with a certain feeling (NASW & ASWB, 2013). As we have previously noted,
self-​reflection is important for every social worker. Therefore, we bring your attention
to a method of conducting supervision that emphasizes greater self-​reflection and self-​
awareness through the practice of reflective supervision (Wightman et al., 2007). In this
method, the focus of supervision is to provide a space for supervisees to think not only
about the work they are doing in their respective settings but also to reflect on how their
feelings had an impact on the encounter. Reflective supervision encourages the supervi-
sor and supervisee to address any impediments to progress that may be found in worker,
client, or both. This method of supervision can be conducted individually or within a
group. In addition, reflective supervision can take on different forms to suit the needs of
the practice setting.
A reflective supervisor explores case material with the supervisee in such a way that
they create the time and space to reflect on the relationship between worker and client,
as well as addresses the administrative pieces of the job. In this way of working, the rela-
tionship is the foundation for reflective supervision that allows honest reflection to occur
(Harvey & Henderson, 2013). This style of supervision requires that there is a strong
working relationship that includes an agreement to work in an open, honest, and thought-
ful way. Many methods of supervision tend to focus more on administrative tasks and
education for novice practitioners and to spend less time on reflection and insight. In this
style of supervision, there are explicit expectations for both the supervisor and supervisee
that are stated prior to beginning their work together. These respective expectations, out-
lined by Wightman and colleagues (2007), are as follows:

A Reflective Supervisor
• Is consistent with meeting time and place;
• Is on time, open, curious, and emotionally available;
• Treats the time as sacred and guards against interruptions;
• Works with the supervisee to set the agenda;
• Respects strengths of supervisee and follows his or her pace;
• Observes and listens carefully, is reassuring, and gives specific feedback;
• Suspends harsh or critical judgment and focuses on increasing supervisees’
awareness and insight;
• Invites the in-​depth sharing of details about a particular situation;
• Listens for the emotional experiences of the supervisee;
• Is empathic in naming and responding to the experiences;

180 • Moving Beyond Assessment

 • Creates a safe space for the supervisee to have and talk about feelings;
• Maintains a shared balance of attention on client and supervisee; and
• Prepares for the next meeting by reflecting on previous ones.
A Reflective Supervisee
• Participates in setting up time and place of regular meetings and sticks to the
schedule;
• Comes to supervision meetings open and emotionally available;
• Is prepared to discuss particular details of his or her work;
• Increases awareness of and reflection on feelings experienced in the work;
• Operates from a stance of openness to sharing those feelings with the
supervisor;
• Explores the relationship between feelings and the work one is doing;
• Tells the supervisor what kind of support is needed and then is open to receiving
that support;
• Remains curious and open to new interpretations;
• Suspends critical or harsh judgment of self and of others; and
• Prepares for the next meeting by reflecting on previous ones.

Some of you may be receiving this type of supervision if your supervisor is trained in
psychodynamic theory and has had specific training in methods of supervision. If you
do not, and this type of supervision is attractive to you yet not available in your setting,
it is perfectly appropriate for your professional growth and learning to contract outside
supervision.

FINAL THOUGHTS ON SUPERVISION

The relationship between supervisor and supervisee has the potential to provide pow-
erful and rich learning and growth opportunities. Due to the power imbalance, there is
the potential for supervisees to feel vulnerable within it. However, with support, trust,
and empathy, this relationship has the potential to serve as a launching pad for signifi-
cant professional development. Social workers are never truly “done” with supervision.
When can you ever know all there is to know? When are you truly free from blind spots
in your work? Even seasoned practitioners need the ongoing support that supervision
brings. At its most basic, supervision provides a quiet time and space to reflect on the
work we do, obtain feedback from another practitioner’s point of view, and plan for the
care of the clients we serve. While it is mandatory at the beginning of one’s career, we
encourage all readers to find ways to infuse supervision into their professional lives well
beyond the mandatory period. Whether you use individual, group, or peer supervision,
finding colleagues to whom you can turn for guidance and support in the work will be
a treasured resource in your career. These relationships can last for years, even decades,
and create communities of professional support that are invaluable.

Supervision • 181
CHAPTER 16 RESOURCE GUIDE
SUPERVISION GUIDE
National Association of Social Workers (NASW): D.C. Metro Chapter. (2013). Best prac-
tice standards in social work supervision. Retrieved from http://​w ww.naswdc.org/​practice/​
naswstandards/​supervisionstandards2013.pdf

SAMPLE SUPERVISION AGENDA

The agenda can also serve as a record of what was discussed in supervision. It should be
kept confidential, as it will often have client information on it. One example of an agenda
is as follows:
Supervision Session
1:00–​2:00 p.m.

I. Review of the week: identify one success and one area for improvement
II. Follow-​up questions on motivational interviewing training
III. Report on client contact this week
  I V. Questions about intervention plan for M.J.
  V. Debriefing of family session with C.K. and parents
VI. Progress report on recruitment for support group
VII. Planning of upcoming vacation—​client coverage and office staffing needs
VIII. Review of grant report
   I X. Plans for upcoming week

182 • Moving Beyond Assessment

 CHAPTER 17

TECHNOLOGY AND
SOCIAL MEDIA

B efore reading the rest of this chapter, think about your own presence
on social media sites. Now, think about the clients you serve viewing that information.
Would you show clients pictures from your vacation? Think about potential employers
typing your name into a search on Google. What will they find? Would you want them
viewing photos from your college reunion? While you have a right to your privacy and
personal life, becoming a social worker also means projecting a professional image. We
hope that as you read this chapter, you begin to think about your own use of the Internet
and what information is available about you and how that information is consistent with
the professional reputation and image you hope to establish and maintain in your career.
Social media is one of the most ubiquitous forms of interaction in our culture today.
One in every nine people on Earth is on Facebook. Each Facebook user spends on aver-
age 15 hours, 33 minutes per month on the site. Twitter is adding nearly 500,000 users
each day. Most communication is conducted via e-​mail, text messages, instant messages,
tweets, and other technology (Dombo, Kays, & Weller, 2014). Practitioners should have
the freedom to participate in these forums for both personal and professional purposes.
Practitioners should also be aware of how the use of these technologies has an impact
on the clients they are serving. Conversely, if practitioners do not choose to utilize these
forms of technology, we also believe they have an obligation to understand the cultural
and relational significance of the modes of communication to better understand their
clients.
Given these statistics, technology and social media are changing the landscape of
social services and professional relationships. Beginning social work practitioners should
be cognizant of ways their personal use of social media will have an impact on their clients,
as well as how their professional use should be done in an ethical manner. Technological
advancements have enabled clients to engage with practitioners and their services in new
ways, raising a multitude of ethical dilemmas. While we cannot predict what the future
holds in this area, we discuss the current ethical concerns, as well as some of the advan-
tages and disadvantages of these technologies in working with clients.
ETHICS, TECHNOLOGY, AND SOCIAL MEDIA
Many social service organizations utilize social media to promote their programs, engage
with the communities they serve, and raise their visibility to funders. However, the poli-
cies surrounding social media within these organizations may not be clear. As such, many
ethical dilemmas arise in agencies surrounding their use of social media, especially when
it comes to how social media is used in relation to the clients they serve. For example, con-
sider the ethics of asking clients to “like” the website or become a “fan” of the Facebook
page for your agency. Would it be a dual relationship for clients to write reviews of or
testimonials regarding you or your agency on Yelp or other sites, whether solicited or not?
Without clear statements on these issues by professional organizations, we must turn to
our Code of Ethics(COE) to help in the decision-​making process.
Unfortunately, the COE for social workers (National Association of Social Workers
[NASW], 2008), like many other professions, has yet to catch up to the current cultural
norms concerning use of technology. However, there are some guiding principles that can
help the practitioner make choices about how to proceed. If you begin with the principle
regarding the importance of human relationships, we see that the COE places an emphasis
on human relationships between and among people; relationships are seen as central to
the change process. While the current COE does not directly address the use of technol-
ogy in relationships, it is possible that technology has the potential to be both a help and
a hindrance to “strengthen relationships among people in a purposeful effort to promote,
restore, maintain, and enhance the well­being of individuals, families, social groups, orga-
nizations, and communities” (NASW, 2008, p. 6).

PROFESSIONAL USE OF SOCIAL MEDIA

A social worker may use technology in an agency setting for a variety of reasons. For
example, technology can make it easier to set up, change, or cancel appointments. It can
also help with communication in a timely and economical manner to groups of people
on particular issues. Many agencies have electronic newsletters, online scheduling for
appointments, and blogs on issues such as mental health, social justice, and community
organizing. In addition, many programs have transitioned to the use of electronic client
records. These advances make it easier for social workers to communicate and connect
with other professionals. However, there are risks associated with technology. For exam-
ple, keeping client records on computers can leave the information at risk of hacking or
being seen by others who are not the intended recipients of the communication, therefore
violating a core principle of confidentiality (Reamer, 2013).
In addition to confidentiality concerns with client records, there are important con-
siderations regarding the confidentiality of electronic communications with clients. E-​
mail has become a common form of communication among professionals and between
social workers and their clients. However, when communicating by e-​mail, it is important
to consider whether it is being sent to the correct person. Who will see it? Does it in any
way contain sensitive or confidential information such as why the person is meeting with

184 • Moving Beyond Assessment

you, what agency you represent, or other information that could indicate the person is a
client of your agency?
The use of telephones for communication involves a form of technology. When
placing a telephone call, does your agency name appear on caller identification? When
I (E.D.) worked at a rape crisis center, our phone number was not tied to the name of
the agency for purposes of confidentiality. So, when we would call a client, “Rape Crisis
Center” would not come across a caller ID system. Many agencies have similar policies.
However, if someone autodialed a return call to that number, the person answering the
phone would say “Rape Crisis Center, this is Eileen, how can I help you?” This response
would mean that a call from the center was placed to that phone number. There were
many occasions when I would answer the phone and someone would say: “Why did
someone from a rape crisis center call my house?” Obviously this person did not know
that someone in his or her home, such as a spouse, child, or roommate, was receiv-
ing services from the center. This example demonstrates that even the most earnest
attempts at keeping agency and client contact information confidential can be thwarted
by technology.
Concerns about confidentiality and fostering connection in relationships with cli-
ents are also related to the principle of cultural competence (NASW, 2008). The culture
of many of our clients is to communicate through the use of e-​mail, FaceTime, text,
and so on. If we do not utilize these means of communication, are we disrespectful of
our clients’ culture? However, some clients due to financial restraints may not have
access to various technologies, and we may have to work with them to find a compro-
mise solution that protects and supports them in the work while protecting your own
boundaries.
Striking a balance between being accessible via technology and keeping the bound-
aries of the professional relationship is vital, yet difficult to navigate. Most practitioners
need to find their own comfort level with this balance and be consistent with all clients.
We strongly recommend discussing your use of technology with clients at the beginning
of the helping relationship as a part of the informed consent discussion. This is particularly
important to be in compliance with the Health Insurance Portability and Accountability
Act of 1996 (HIPAA). HIPAA calls on us to safeguard client information, including case
notes, particularly related to information stored electronically. This also means that we
cannot share client information, or even acknowledge that someone is a client at our
agency, without written consent. If your agency provides services using technology, then
you should discuss these parameters with your supervisor and be sure that clients are
made aware of the potential threats to confidentiality (Santhiveeran, 2009).
We recommend that you and your supervisor discuss the agency norms regarding
technology and then discuss how those norms fit with your own comfort level. For exam-
ple, many agencies that provide community-​based services do not have landlines for their
workers because they are out in the field more than in the office. As a result, many of the
workers may use their personal cell phones as their primary form of communication with
other agency workers and their clients. While this may be the norm, you should consider
what sharing your personal cell phone number with clients might mean. It may mean that
now, for all of eternity, even when your internship or position ends, your clients will have

Technology and Social Media • 185

your personal cell phone number and can reach you no matter where you go. They can
then text, call, or send you pictures any time they like for as long as you have that phone
number. Therefore, it is important to process and think through how to balance the needs
of your clients as well as your own.
Finally, technology has made it easier to enact the principles of public participation and
social and political action. The COE states that professionals should “ensure that all people
have equal access to the resources, employment, services, and opportunities they require
to meet their basic human needs and to develop fully. Social workers should be aware of
the impact of the political arena on practice and should advocate for changes in policy
and legislation to improve social conditions in order to meet basic human needs and pro-
mote social justice” (NASW, 2008, p. 27). Social media is used by organizations to engage
in advocacy toward this end. Sending out e-​mail blasts, tweeting the results of studies,
and organizing thousands of people through one touch of a smartphone are examples of
positive ways technology is advancing social work values (Csiernik, Furze, Dromgole, &
Rishchynski, 2006).

PERSONAL USE OF SOCIAL MEDIA

Like it or not, social workers’ personal use of social media can have professional impli-
cations. The COE (NASW, 2008) states that we must comport ourselves in our private
conduct in such a way that it does not interfere with our professional responsibilities. We
also must take care to avoid misrepresentation of our personal beliefs and practices as our
own and not representative of our profession or agency. Finally, our behavior should
reflect positively on the integrity of the profession. These ethical standards highlight that,
in the course of our personal lives, we are still viewed by the public and our clients and
communities we serve as a social worker who represents the profession. This representa-
tion is true in the online community as well. Our personal use of social media should be
done in such a way that is respectful of our profession, our colleagues, and the clients and
communities we serve. We strongly encourage that professionals make use of privacy set-
tings or develop an alternative name for personal Facebook pages or Twitter accounts as
these strategies can help create a boundary between the personal (private) and the public
(professional). For example, professionals who use Twitter accounts have been found to
tweet at handles that cross personal and professional lines, such as @socialjerkblog or
@fatsocialworker. What are the implications of this for the profession? How savvy can we
expect the public to be in making distinctions between our online personal selves and our
professional selves (Dombo et al., 2014)?
It is important to remember, however, that technology changes rapidly, and one can-
not ever be assured that his or her private pages are not being hacked or accidently made
public (Dombo et al., 2014). If you would not show your clients photos from your vacation,
think about where you are posting them online. While some self-​disclosure is inevitable
in our increasingly technological world (McWilliams, 2004), we have an ethical responsi-
bility to our professional community and the communities we serve to set boundaries and
limits with our own personal use of social media.

186 • Moving Beyond Assessment

 CLIENTS’ USE OF TECHNOLOGY
Our clients’ use of technology is also important to consider. For example, many clients
who seek services from social workers and other practitioners will turn to the Internet
to see what information they can find on a variety of topics. Some intentionally look for
personal information about the practitioner they are planning to see, while others find
this information accidentally. In exploring how often clients seek and find information
about a therapist with whom they are working, researchers found that 70% of the study
participants reported having found personal information about their therapist on the
Internet (Kolmes & Taube, 2011). Of those who found personal information, 87% found
it intentionally, and only 13% found it accidentally. Finally, for those who participated in
this study, most of the participants did not disclose that they had done this (Kolmes &
Taube, 2011).
The Kolmes and Taube (2011) study also reported that the majority of the clients
stated that their reaction to finding such information was either positive or neutral.
The participants also reported feelings of curiosity, interest, and reassurance when
they found information about their therapists. Nonetheless, in addition to these posi-
tive feelings, participants also frequently reported feelings of guilt, awkwardness, and
embarrassment. In one particular case, a client experiencing erotic transference with a
therapist saw pictures of his therapist in a bathing suit online and was so distressed that
he left therapy (Kolmes & Taube, 2011). Depending on what the client found, as in the
previous example, we are fairly confident that these experiences influenced the relation-
ship with the practitioner in multiple ways and distracted from the focus on the client’s
presenting issues.
In addition to using the Internet to gather information, clients provide information on
the Internet through the use of blogs (Glassgold, 2007). Clients have shared publicly what
it felt like when they found information about their therapists regarding confidentiality,
what it was like to learn information they did not want to know, and how that informa-
tion complicated and entangled boundaries and led to greater difficulties detaching after
termination. The clients used words such as awkward and creepy with regard to learning
about their therapists online. While some approaches to boundaries with online interac-
tions are viewed as too rigid or cautious (Glassgold, 2007), it is the social worker’s respon-
sibility to make every attempt to keep private information private.
Another ethical issue that we mentioned is inviting clients to comment on the
agency’s social media sites. To avoid conflicts of interest (NASW, 2008) in working
with clients, practitioners and their agencies should think carefully before asking cli-
ents to endorse the services on a website or Facebook page. Asking clients to do this
could be seen as being in the agency’s best interest, but not the client’s. In addition,
such requests have the potential to exploit the professional relationship. Also, asking
clients to post blogs on the agency website about their experiences could be viewed as
either empowering to the client or as creating a dual relationship (Dombo et al., 2014;
NASW, 2008). These kinds of arrangements can create ethical dilemmas that need to
be carefully considered with supervisors and agency leaders before making decisions
about how to proceed.

Technology and Social Media • 187

USE OF TECHNOLOGY TO DELIVER SERVICES
There are many settings that are using technology to deliver services to clients. This is
commonly referred to as telehealth and is particularly beneficial for people living in rural
or hard-​to-​reach areas, people who are homebound, or people who require a sense of ano-
nymity to reach out for support (Reamer, 2013). There are many online support groups,
crisis hotlines, and self-​help resources that clients can access in lieu of traditional face-​to-​
face counseling meetings.
Technology is also being used in the form of smartphone apps and self-​g uided inter-
ventions that can be used as adjuncts to traditional counseling or on their own (Barak &
Grohol, 2011). While there are benefits to this mode of delivering services such as those
we have listed, there are drawbacks as well. For example, it can be difficult to build rap-
port and engage clients when each person is unable to read nonverbal cues. Also, another
downside to the use of telehealth is that there is the potential for the meaning of e-​mails
and text messages to be misconstrued because there is no context provided with these
forms of communication (Menon & Rubin, 2011).
If your setting is providing services utilizing technology, we strongly encourage
you to be sure that clients are made aware of the limitations of this form of service
delivery as a part of informed consent processes (NASW, 2008). An important aspect
of professional competence is knowing about the range of services that exist and being
appropriately trained and supervised in carrying out these interventions (NASW &
Association of Social Work Boards, 2005). In addition, social workers must evaluate
the client’s appropriateness for interventions that are delivered via technology. Kraus,
Stricker, and Speyer (2011) stated that there are a few situations in which this modality
is contraindicated:

• Client has thoughts or hurting him-​or herself or others

• Client is in an emergency situation
• Client has a history of suicidal, violent, or abusive tendencies
• Client is having delusions or hallucinations
• Client is an active alcohol or drug abuser

These types of situations require more intensive work, and the worker may need to have
more direct interaction with the client to monitor such cases. In addition, by not taking
a more direct approach, social workers may be putting themselves in a legally vulnerable
position if they continue to use telehealth technology knowing that their clients require
more intensive supervision. These potentially risky situations raise a concern with regard
to licensing and technology. Many states do not have specific regulations regarding the
delivery of services utilizing technology or specify education and training requirements,
leaving many social work practitioners with little guidance and information regarding
how best to manage such client situations. See Dombo et al. (2014) for a full listing of this
information by state.

188 • Moving Beyond Assessment

FINAL THOUGHTS ON TECHNOLOGY
Because you are at the beginning of your career as you read this, you can enter your career
in such a way that it is responsive to the trends in social media use personally and profes-
sionally. By setting good habits early, you will feel confident that your professional repu-
tation will be protected when viewed through the eyes of the Internet. Some suggestions
(Dombo et al., 2014) are presented here to start your thinking about this:

• Regularly monitor your representations on the Internet (e.g., set up a Google Alert
for yourself).
• Clean up your online presence to eliminate information that may be dated or
problematic for clients to find.
• Become educated about privacy settings on social media sites you participate in,
their limits to privacy protections, and risks of hacking and other unintentional
breaches in privacy.
• Be as thoughtful in your digital presence as you are in the “real world” (e.g., ask yourself
before you post something, “Would I be comfortable saying this to a client directly?”).
• Review your state’s regulations and ongoing legal changes relevant to the delivery
of social work services through technology and other online activity.
• Be prepared for how you to handle situations where clients bring up information
they have found about you online; integrate this into sound clinical practice, just
as you would discussions about race, gender, religion, and culture.
• Create online practices and policies that account for online issues and boundaries
(see summary guide for examples) and integrate them into your informed consent
procedures or using client contracts.
• Use an alternative name for your personal online presence that is significantly
different from your professional one.
• Establish guidelines and principles to help guide online use by social workers if
you are the head of an agency or a supervisor.

CHAPTER 17 RESOURCE GUIDE: SUGGESTIONS

FOR CREATING A POLICY ON TECHNOLOGY
It is strongly suggested that all social service organizations as well as independent prac-
titioners create policies for use of technology by workers as well as for interactions with
clients utilizing technology (Dombo et al., 2014). Some suggestions for what to include
are as follows:

• Organizations should indicate who can and who cannot post official messages on
social media sites.
• There should be specific people designated to handle Twitter accounts to both
send and respond to messages.

Technology and Social Media • 189

 • It is generally not recommended to ask clients to “friend” or “fan” an organization’s
Facebook page as this can create a dual relationship. Instead, ask other providers
who are referral sources to do this.
• Employees should be given clear guidelines regarding how to protect client
information in databases and computerized health records systems and should
know under what circumstances they can share protected information.
• Clients should be told about electronic health records or other use of technology as
part of informed consent.
• If using e-​mail to communicate with clients, the policy should clearly state the
threats this format can pose to confidentiality.
• Parameters concerning sending and receiving e-​mails or text messages from clients
should be clearly stated.
• Consider setting policies about not accepting friend requests or LinkedIn requests
from current or former clients to protect their privacy.
• Consider specifying the type of videoconferencing software used to provide
teletherapy or conduct clinical supervision if applicable. The software utilized
should be secure.

190 • Moving Beyond Assessment

 CHAPTER 18

BEGINNING KNOWLEDGE
OF THE BRAIN AND ITS
FUNCTIONS

A s with virtually every chapter so far, it is beyond the scope of this book
to cover everything you need to know about the brain. However, we frequently hear how
often practitioners feel pressure to understand and include more knowledge of neurobi-
ological factors in their assessments and interventions with clients. To alleviate some of
this pressure, this chapter provides an overview of the concepts that they may hear about
in their work. This content includes some of the essential features of psychological testing
and a summary of what is currently known about neurobiology and brain functioning.
In addition, regardless of the practice setting, many nonmedical helping professionals
work with clients who are prescribed at least one psychiatric medication by their primary
care provider or a psychiatrist. Given that social workers are often the individuals who
may hear from the clients about their experiences with these medications, we feel strongly
that, at a minimum, social workers should know the broad categories of the families of
medications so that they are attuned to any medication-​related concerns expressed by
their clients. We recognize that this knowledge is continually evolving. As such, we pro-
vide general guidelines and encourage readers to continue to seek new knowledge.

NEUROBIOLOGY
WHAT IS NEUROBIOLOGY?
The study of neurobiology in fields such as social work and psychology has increased in
the last few decades, yet what we know is still only a drop in the bucket. We study the
brain and nervous system to better understand how they influence human behavior. The
brain has been described as “the social organ of the body” (Siegel, 2007, p. 48) because
it is connected to the other organs of the body and connects us with other individuals.
In this way, our knowledge of brain functioning can help us comprehend the behavior of
our clients, and perhaps more important, it can be used to help clients better understand
themselves.

WHAT IS THE BRAIN?

Weighing in at 3 pounds, the brain is the most powerful organ in the human body. There
are many models of the brain in textbooks (e.g., Farmer, 2009; Siegel, 2007), and you
can find some great images and videos with a quick Google search on the brain (see the
summary guide for recommended sites). You can also find workshops, seminars, or short
courses on neurobiology in continuing education or postgraduate educational programs.
However, the following provides a beginning understanding of the brain (Farmer, 2009;
Siegel, 2007):

1. The cerebral cortex is the outside of the brain; it handles the complex functions
of attention, perception, and planning. Within the cortex are a number of dif-
ferent areas called lobes that have different functions, such as those related to
motor activity. Also within the cortex are several columns responsible for activ-
ities such as seeing and hearing and that connect through neurons to trans-
fer information. The cerebral cortex is divided into right and left hemispheres,
which are connected by the corpus callosum:
a. The right brain regulates affective experiences then transfers that knowl-
edge to the left brain.
b. The left brain controls verbal and analytic functions.
2. The prefrontal cortex is the frontal lobe and is considered to be the “executive
center” of the brain that addresses regulating, and controlling emotions and
behaviors.
3. The limbic system is under the cerebral cortex and houses a number of structures,
including the amygdala, hippocampus, thalamus, and hypothalamus, which are
primarily responsible for the creation of emotions and moods, the appraisal of
meaning, the creation of emotional attachment, and implicit memory.
4. The brainstem (also known as the “reptilian brain”) regulates basic processes of
the heart and lungs and sleeping and waking states and is the conduit of infor-
mation from the spinal cord. This part of the brain is where our fight-​fl ight-​
freeze reactions are housed. It is seen as the most primitive part of the brain
because it is dedicated to our basic survival instincts.
5. Neurons are the nerve cells within the brain that communicate with one another
using signals. The neurons signal to one another and create feelings, thoughts,
and memories.
6. Neurotransmitters are the chemicals neurons use to signal and communicate
with one another. There are two types of neurotransmitters with a variety of
functions. Those that are inhibitory (e.g., serotonin) help to calm and balance

192 • Moving Beyond Assessment

 mood. Excitatory neurotransmitters, such as dopamine, stimulate the brain and
help individuals to focus.
7. Mirror neurons are considered to be a certain type of neuron that takes a per-
ception of what you see and then prepares you to imitate that behavior in the
same way. These special neurons are crucial to social and emotional functioning
because they help us anticipate the feelings and intentions of others. Mirror
neurons are linked to the development of empathy and the ability to inter-
pret social cues. They “connect the observed and the observer” (Farmer, 2014,
p. 268).

WHY CARE ABOUT NEUROBIOLOGY?

Although our understanding of how the brain works is limited, the knowledge that is
available can be an important part of understanding human behavior. Neuroscience is
seen as the “missing link” in the helping professions because knowledge of the brain fills
in gaps in our understanding of mental health and illness (Farmer, 2009, p. 1). In other
words, this knowledge has transformed practice. Whether you work with children in
foster care, older adults with Alzheimer disease, women with substance use issues, com-
munities recovering from a natural disaster, or federal policy initiatives for veterans, it
is essential for social workers to have a basic knowledge of the role of the brain in the
bio-​psycho-​social-​spiritual framework of human behavior. This knowledge helps us more
fully understand the human experience (Badenoch, 2008; Farmer, 2009).
Understanding the structure and various functions of the brain has great utility across
a number of fields of practice. For example, research on autism spectrum disorders is cur-
rently exploring potential deficits in mirror neurons (Fan, Decety, Yang, Liu, & Cheng,
2010). Researchers seeking to better understand substance abuse disorders are investi-
gating the role of the neurotransmitter dopamine in these disorders (Bennett & Petrash,
2014). Another example comes from trauma research, where there are attempts to deter-
mine the impact of trauma on the development of the limbic system in children (Weber
& Reynolds, 2004). Practitioners can utilize knowledge of the brain to help clients who
struggle with these issues, both in understanding the origins of these issues and how to
address them. What is most encouraging about much of this research is that as clients
learn new ways of being in the world or have new experiences, their brains can change.
This change process can be explained and understood through the concept of plasticity
(Siegel, 2007).
In my (E.D.) work with trauma survivors, it is particularly helpful to explore the role
of the fight-​fl ight-​f reeze response with their behavior. When a client asks questions such
as “Why didn’t I just run?” or “Why couldn’t I speak up?” I am able to talk with them
about the way our brains are wired to respond to distress. The same is true for talking with
clients about memory and dissociation and the more recent understanding about how
traumatic memory is stored in the brain, and when we avoid remembering, it weakens that
memory. When a client wonders why they dissociate when overwhelmed by traumatic
experiences, I can explain that it is the brain’s way of protecting the client from what is

Beginning Knowledge of the Brain and Its Functions • 193

happening. While they cannot physically escape, the brain provides a way to mentally
shut down to avoid the experience.

BRAIN PLASTICITY
Brain plasticity is a term that explains the way new experiences can have an impact on
the brain. In essence, the concept means that the brain changes. The idea of brain plas-
ticity is a relatively new concept (Farmer, 2009); until recently, the prevailing thought
was that the human brain stopped developing in adolescence. It seems like such an
antiquated notion now, akin to doctors treating a cold with leeches. The evolving sci-
entific understanding of the brain tells us two important things: (a) The plasticity of
the prefrontal limbic cortex makes the brain particularly vulnerable to disorganization
that results from negative experiences; and (b) the prefrontal cortex is also the area of
the brain amenable to reordering, restructuring, and repatterning through support-
ive counseling and therapy (Farmer, 2009; Montgomery, 2002). Therefore, plasticity
means that the brain is both negatively and positively impacted by experiences. What
is especially important for social workers to remember is that the brain changes in
response to environmental conditions. The concept of plasticity speaks to the role of
an individual’s environment and how it has an impact on his or her brain’s structure;
harmful environments wire neurons a certain way, while safe and nurturing environ-
ments create different pathways.
For example, research on the brain has demonstrated a connection between traumatic
stress and brain development. Specifically, early trauma has been shown to negatively
impact attachment, coping skills, and emotional regulation (Allen, 2001). These expe-
riences then have an impact on the organization of the limbic system, which then has
an impact on an individual’s future ability to adapt to new and changing environments
(Cohen, Tottenham, & Casey, 2013; Garland & Howard, 2009; Schore, 2001; Weber &
Reynolds, 2004).
One of the ways adaptation is difficult relates to the challenges faced by individu-
als who have a trauma history. These folks often struggle to describe their trauma in
a cohesive narrative. The reason for this challenge is because traumatic experiences
inhibit neural integration of the events. In other words, the brain cannot process the
information from such an overwhelming event, and some information is lost and frac-
tured in how the person remembers the event. Therefore, one of the goals of an inter-
vention is to help the client create a more cohesive narrative of their past traumatic
experiences. Research continues to show that the brain, as a result of plasticity, can be
altered, most often through the experiences of a supportive and reparative relationship
(Siegel, 2003). Neural integration is the outcome of attuned relationships we have with
our clients (Siegel, 2003). This research reinforces the importance of forming effective
relationships we discussed in Chapter 2. In these relationships, we are not only helping
our clients to gain new ways of being in the world through the development of new
patterns, but also helping to change the brain and the way their brain functions on a
physical level.

194 • Moving Beyond Assessment

NEUROSCIENCE AND MACRO PRACTICE
Neuroscience is not just relevant for social workers in direct practice or clinical set-
tings. A critical connection also exists between social justice issues and neuroscience.
The stress that often results from a lack of medical and mental health coverage, as well
as experiences of oppression in various forms, can have serious negative effects on the
brain. This information can be useful to clients who are struggling to understand their
own challenges. Through psychoeducation, social workers can help clients understand
how their environment has played a role in their mental health conditions. From a
macro lens, this knowledge directly speaks to the need to work for societal change
to reduce negative environmental forces in the lives of our clients (Ivey & Zalaquett,
2011). Therefore, macro interventions, such as community organizing and policy
advocacy, should address the impact that oppression, trauma, and stress have on brain
development.
Neuroscience research is critical to bridge the micro and macro efforts of our work.
Advocates for mental health research and services can use knowledge developed from
neuroscience to show how the processing of events, memories, and feelings with a social
worker or other professional in a safe holding environment grows new dendrites in the
brain and strengthens neural pathways that would otherwise atrophy. Neuroscience pro-
vides solid evidence to support that what we do as practitioners has positive effects on
the brain (Ivey & Zalaquett, 2011; Matto & Strolin-​Goltzman, 2012; Montgomery, 2002).

PSYCHIATRIC MEDICATIONS:
UNDERSTANDING YOUR ROLE
There is a clear connection between medications for psychiatric conditions and neurobiol-
ogy. Practitioners whose clients are taking psychotropic medications must attend to these
connections to best understand and serve the client (Farmer, 2014). For practitioners
who work on macro-​level issues, understanding the connection between medications
and mental well-​being is crucial to advocating on behalf of these populations. For practi-
tioners who work directly with clients who use prescription or nonprescription drugs, it
is essential to explore the impact they are having on brain functioning, emotional well-​
being, and ability to be attuned with others in their lives and with their internal processes.
Many clients helped by social workers and other practitioners have chronic mental
health diagnoses that require ongoing medication monitoring and compliance. Referring
to psychiatrists and coordinating care with these providers are some of the most common
tasks performed by social workers in clinical settings (Bentley, Walsh, & Farmer, 2005).
These tasks are in line with the code of ethics for social workers, particularly the prin-
ciples of social justice, dignity and worth of the person, valuing the central importance
of human relationships, and striving for competence in our practice domains (Bentley
& Walsh, 2006). When working with clients who rely on access to psychiatric care and
affordable medications to live independently and manage their mental health challenges

Beginning Knowledge of the Brain and Its Functions • 195

with dignity and grace, it is incumbent on practitioners working with these populations
to collaborate closely with psychiatrists to coordinate care.
Your role with regard to medications will depend in large part on your practice setting.
However, you will likely be advocating on behalf of the client; consulting with family
members about the need for medications; supporting the physician’s recommendations;
counseling the client about the struggles of medication compliance; and monitoring the
medication side effects. In other settings, you may be providing psychoeducation about
medications and conducting research on the psychosocial effects of medications on
particular client populations (Bentley & Walsh, 2006). In all instances, to be a compe-
tent practitioner, you will need a good working knowledge of psychotropic medications
(Farmer, Bentley, & Walsh, 2006).
Your settings and populations may require other types of skills and knowledge. For
example, when working in settings where the clients have a substance use disorder and a
chronic mental health diagnosis that requires psychotropic medication (often referred to
as a “dual diagnosis”), your role will include carrying out integrated treatment to help the
client understand the interactions between prescription and nonprescription substances
(Drake & Mueser, 2000). When working with diverse populations, you will also need
to educate yourself about the differences in effects of psychotropic medications depend-
ing on the ethnic, social, and cultural differences of your clients (Ruiz, 2000). This is an
all-​too-​often overlooked issue, as many medications are tested on Caucasian study par-
ticipants and not adjusted for other populations (Farmer, 2014). Finally, there are some
groups viewed to have specific needs related to psychotropic medications. If you are work-
ing with older adults, children, adolescents, and pregnant or postpartum women, you will
need specific education related to these specific concerns (see the National Institute of
Mental Health [NIMH] link in the summary guide).
In the role of counselor, your main job is to understand the common side effects of the
medications your client is taking, empathize with the difficulties of compliance, and work
together for the best possible outcome. It is beyond the scope of this chapter to address
all the side effects of all the medications and how they will differ for each individual and
address the potential interactions of psychotropic drugs with other medications the client
is taking. However, it is crucial to understand that many clients struggle with adherence
to the prescribed medication regime. Often, the experience of feeling better due to the
effects of the medication leads the person to believe he or she is better and does not need it
any more. Stopping the medication on one’s own without the help of the psychiatrist can
be dangerous. Each individual has his or her own unique experience of a medication, and
this subjective interpretation can have an impact on adherence and therefore the outcome
of services you are providing (Bentley, 2010).
In my (E.D.) practice experience, many clients grapple with the negative side effects
of medications and wonder if they outweigh the benefits of adhering to them. For exam-
ple, one of my clients was experiencing clinical depression as the result of a history of
childhood sexual abuse trauma. Her depression was connected to her inability to feel safe
being sexually intimate with her husband, and she was beginning to feel hopeless about
her ability to overcome these dynamics. One of the side effects of her antidepressant med-
ications was a decrease in sexual arousal and interest. This was greatly distressing to her
as she felt it would make her presenting problem worse, not better. In this situation, the

196 • Moving Beyond Assessment

client and I spoke at length about her dilemma. I encouraged her to share these concerns
with her psychiatrist, and she was able to work with the doctor to find a medication that
was a better fit.
If the client had not felt able to convey these concerns to her psychiatrist, I would have
asked her to sign a release of confidentiality so I could speak on her behalf and advocate
for her needs. These types of situations draw attention to the need to develop good work-
ing relationships with psychiatrists, as well as all practitioners from other disciplines. In
the summary guide, you will find recommendations for referring clients to psychiatrists
and developing working alliances with them. As an advocate for the client’s needs, you
can demonstrate that psychiatrists are typically more than willing to collaborate on their
care and want the best outcome for their mental health. Over time, you can encourage
clients to ask specific questions, such as the following:

• How long will it take for me to feel the effects of the medication?
• Is this a generic label or trade label? Is there a difference?
• What should I do if I forget a dose?
• Are there programs or resources available to help defray the cost of
medications?
• Are there any negative interactions with my other medications?
• What food or drink (including alcohol) should I avoid while on this medication?
• Is there a fact sheet on this medication that I can take home with me?
• What are the common side effects?
• If I decide to stop taking this medication, will you talk with me about safe and
effective ways to do this?

The goal is for the client to become the leader of this team, which includes you and the psy-
chiatrist, working together to manage the symptoms of the client’s presenting problems
toward the best outcomes possible.

FINAL THOUGHTS ON NEUROBIOLOGY

AND MEDICATIONS
It is normal to feel confused and overwhelmed by the content of this chapter. You do
not need to be a neuroscientist or psychiatrist to embrace your role as a practitioner who
understands these complex ideas. Part of competent practice is staying current on the
brain science behind mental health and the psychotropic medications designed to be part
of a comprehensive treatment approach for wellness. Do not shy away from this content.
Spend time becoming familiar with the classes of medications listed in the summary guide
and the basic parts and processes of the brain that relate to mental health. You will feel
more prepared for your work, whether it is advocating for funding for research, creating
policies on mental health treatment, linking clients with psychological testing, or helping
a client’s family understand the role of medications in the management of symptoms.

Beginning Knowledge of the Brain and Its Functions • 197

CHAPTER 18 RESOURCE GUIDE
This guide provides some links to web resources on the brain and neurobiology, as well
as links to current information about psychotropic medications. Finally, we present some
guidelines for collaborating with psychiatrists and general information about the major
classes of drugs.

NEUROBIOLOGY
Center for Neuro Skills (CNS). (2014). Brain function. Retrieved from http://​w ww.
neuroskills.com/​brain-​injury/​brain-​f unction.php
Cold Spring Harbor (CSH) Laboratory. (2005–​2009). Genes to cognition. Retrieved
from http://​w ww.g2conline.org/​2022
Dr. Dan Siegel. (2010). Resources. Retrieved from http://​d rdansiegel.com/​
resources/​
Inside the Brain: Weekly Neuroscience Updates (n.d.). Retrieved from http://​inside-​
the-​brain.com
Alzehimer’s Association (n.d.). Inside the brain: An interactive tour. Retrieved from
http://​w ww.alz.org/​a lzheimers_​disease_​4719.asp
Society for Social Neuroscience. (2010). Links & resources. Retrieved from http://​
s4sn.org/​l inks/​
YouTube. (2010). Dr. Daniel Siegel presenting a hand model of the brain. Retrieved from
http://​w ww.youtube.com/​watch?v=DD-​l fP1FBFk&noredirect=1

MEDICATIONS
National Institute of Mental Health. (n.d.). Mental health medications. Retrieved
from http://​w ww.nimh.nih.gov/​health/​publications/​mental-​health-​medications/​
index.shtml?utm_​source=rss_​readers&utm_​medium=rss&utm_​campaign=rss_​
full
U.S. Food and Drug Administration. (2014). Information by drug class. Retrieved
from http://​w ww.fda.gov/​Drugs/​DrugSafety/​InformationbyDrugClass/​
U.S. Food and Drug Administration. (2014). Medication guides. Retrieved from
http://​w ww.fda.gov/​drugs/​drugsafety/​ucm085729.htm
U.S. Food and Drug Administration. (2014). MedWatch: The FDA safety information
and adverse event reporting program. Retrieved from http://​w ww.fda.gov/​Safety/​
MedWatch/​default.htm
WebMD. (2005–​2014). Drugs and medications a-​z . Retrieved from http://​w ww.
webmd.com/​drugs/​index-​drugs.aspx

198 • Moving Beyond Assessment

 GUIDELINES FOR PSYCHIATRIST REFERRAL
AND COLLABORATION
1. Research psychiatrists in your area. Find out what insurance they take and if they
have low-​cost or sliding scale services. Many community mental health agen-
cies employ psychiatrists for their clients, so this can be a good place to start.
Ask colleagues about the psychiatrists to whom they refer; many have special-
ties, such as working with trauma survivors or children. This is important infor-
mation to know before making a referral.
2. Visit the offices of those to whom you will be making referrals. Make a brief
appointment to introduce yourself and your agency or practice. Keep it short
and simple, but make a connection.
3. When making the referral, be sure the client is ready to make an appointment to
avoid diminishing the goodwill of the psychiatrist. While some resistance is to
be expected, unless the client is ready for a serious discussion about medica-
tions, both client and psychiatrist will feel frustrated by the meeting.
4. After the meeting, if the psychiatrist has not followed up with you, be sure to con-
tact the psychiatrist to say thank you for meeting with the client and to ask if
there is information to share that will help with the coordination of services to
the client. If you both have a confidentiality release signed by the client, than
this collaboration is not violating any previous confidentiality agreements.
5. Check in regularly with your client about adherence to the medications pre-
scribed. Explore side effects and any complicating factors that may be prohibit-
ing the client from taking the medication as needed.
6. Find out when the client has his or her next appointment with the psychia-
trist and encourage the client to prepare for the appointment with questions
for feedback that will help the medication regime. You can spend time with
your client role-​playing any interactions with the doctor the client may feel
apprehensive about.
7. Keep in regular contact with the psychiatrist throughout the working relation-
ship to check in regularly and coordinate care. Even if you terminate your work
with the client, be sure to terminate the coordination with the psychiatrist
appropriately.

These guidelines were adapted from Bentley, Walsh, and Farmer (2005).

Beginning Knowledge of the Brain and Its Functions • 199

CLASSES OF PSYCHOTROPIC MEDICATIONS
Class of Medication Some Examples of Common Generic Drugs (Trade Name in Parentheses When Applicable) Used to Treat
Antipsychotics Aripiprazole (Abilify), chlorpromazine (Thorazine), haloperidol (Haldol), Schizophrenia and related
perphenazine, fluphenazine, risperidone (Risperdal), olanzapine disorders
(Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), paliperidone
(Invega), clozapine (Clozaril), iloperidone (Fanapt), loxapine (Loxitane),
molindone (Moban)

Antidepressants Selective serotonin reuptake inhibitors: Depression

Citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac),
paroxetine (Paxil), sertraline (Zoloft)
Tricyclic antidepressants:
Amitriptyline (Elavil), imipramine (Tofranil/​Tofranil-​PM)
Monoamine oxidase inhibitors:
Bupropion (Wellbutrin)

Mood stablizers Some antipsychotics (see antipsychotic section) Bipolar disorders

Lithium, divalproex sodium (Depakote), carbamazepine (Tegretol),
lamotrigine (Lamictal), oxcarbazepine (Trileptal)

Antianxiety Some antidepressants (see antidepressant section) Post-​traumatic stress disorder;

medications Lorazepam (Ativan), buspirone (BuSpar), clonazepam (Klonopin), obsessive compulsive disorder;
chlordiazepoxide (Librium), clorazepate (Tranxene), diazepam (Valium), generalized anxiety disorder;
alprazolam (Xanax) panic disorders; social phobia

Psychostimulants Methylphenidate (Ritalin, Concerta), amphetamine (Adderall), Attention deficit hyperactivity

dextroamphetamine (Dextrostat), dexmethylphenidate (Focalin), disorder
atomoxetine (Strattera)

Source: Bentley &Walsh, 2006; National Institutes of Mental Health.

 CHAPTER 19

FINAL THOUGHTS

W e hope by the end of this book you feel more confident and excited
about your work as a social worker or other helping professional. As we stated in the intro-
duction, we cannot imagine another profession for ourselves, and we hope that you feel
the same level of connection and passion for your future profession. We have shared our
practice experiences with you throughout the book for three main reasons. First, it is our
hope that you will have a better sense of what you will face in working in the multiple
roles and settings. Second, we want you to think through some common pitfalls that can
occur in the early years of working in the helping professions so you can begin to gather
specific ideas about how to avoid them if possible. Finally and most important, we hope
that by thinking through and avoiding some common difficulties, you will have a greater
likelihood of helping your clients achieve their goals.
With these goals in mind, it is fitting that we end this book with some general words
of advice that stem from our own years as practitioners and from our years of teaching
courses to graduate-​level students in social work. These pieces of advice are also based on
our own errors and missteps. We wished someone had passed on to us this advice as we
were beginning our careers. Remember, the journey of developing your professional self
never ends, but these are some good places to begin.

• Practice regular self-​care. Identify your own personal needs to stay emotionally,
mentally, and physically healthy. Each person has his or her own methods to take
care of him-​or herself. I (M.D.G.) get up superearly so I can exercise as I know,
without exercise, I do not sleep as well or eat as well, and I am moodier. On the
other hand, I (E.D.) like to find ways to add humor to my days by finding time to
laugh with colleagues or enjoy a comedy on television or in the movies. Laughter
helps me balance out all the other emotions that arise in me from the work.
• Try to remember what you can change in the world and what you cannot. We
both entered social work with large hopes for our capacity to be change agents.
Yet, we learned quickly that we are one piece in a large puzzle. We do not mean
to imply that we cannot do anything and are powerless. If we believed that idea
we would not be in the field this long. We just want to communicate that it is
important to take the gains and setbacks of our clients in stride. For example, we
 always hope that we can help our clients feel more confident that there are people
who can help them. We hope that this experience with us increases the likelihood
that they are more likely to obtain help in the future. Maybe this level of change is
all we can hope for with some clients.
• Be humble. As mentioned, there are many aspects of a client’s life that influence
what changes he or she is able to make in your work together. As such, it is also
important to remember that when the client does make changes, it was a team
effort. Clients will often thank you and give you all the credit for success in
reaching their goals. Our clients own their work. It is always wonderful to feel that
you are effective in helping a client to reach his or her goals. However, if we cannot
take all the “blame” for when clients do not reach their goals, we also cannot take
all of the credit when they do.
• Create a strong peer group of colleagues. We cannot emphasize enough the
importance of finding a group of colleagues with whom you can share, cry, vent,
or be vulnerable. While this work can be invigorating, it can also be frustrating
and humbling. It is essential to have a group of colleagues with whom you can
share these moments. As you move on in your career, a peer group can support you
through peer supervision, help you continue to learn and grow through the sharing
of new research and practice, and create a community of supportive people who
understand the challenges and rewards of the work. I (E.D.) have been part of a
peer supervision group for years, and I truly value the ability to be vulnerable with
them. I look to this group of seasoned professionals to help me see my blind spots
and teach me something new each time we meet.
• Be honest about what you know, what you do not know, and when you make
mistakes. We are not perfect. We have both been practicing for about 20 years,
yet we still are surprised about what we do not know. Social workers are ethically
mandated to work within our practice areas, which means we need to be honest
about what we know and what we do not know. When we make mistakes, it is
important to talk through these mistakes with a colleague or supervisor and
own them. We cannot emphasize enough the importance of being honest in
supervision. Your learning will be so much greater if you can be honest with your
supervisor about what is going on in your work with clients so that he or she can
help you to gain the knowledge and skills that you need to be more effective. We all
have gaps in our professional knowledge.
• Celebrate difference. Throughout your career, you will work with colleagues,
communities, and clients who are different from you. Do not fear this difference
or pretend it does not exist. Do not feel as though you need to read everything
ever written about every cultural group you might ever encounter in your work.
Approach difference by valuing it. Embrace the richness that comes with different
beliefs, value systems, and cultures. By approaching working across cultures with a
stance of not knowing, you avoid a more defensive or hubristic stance of knowing it
all when you really do not.
• Find your niche. Social work is an incredibly broad field, which is one of its
strengths. However, we have found that when we stumbled through trial and error
and we found populations and settings that matched our passions and intellectual

202 • Moving Beyond Assessment

 curiosities, we were more satisfied professionally. You may be surprised by where
you end up. We encourage you to be open to all sorts of different experiences, as
you never know what will pique your interests. I (M.D.G.) wanted to learn more
about group work, and the only group that was happening in my agency at the time
was a group for adjudicated adolescent sex offenders. Never in a million years did
I think I had an interest in working with this population. I had always (and still
do) worked with survivors of trauma, including sexual trauma. However, the work
was fascinating, and I realized that if I really wanted to stop sexual violence from
happening, it was this population with whom I needed to work. My work in this
group led me back to school for my doctorate and has been a main focus of my
research ever since. You just never know what will strike you until you try it.
• Keep learning. We encourage you to use one-​on-​one supervision, peer
supervision, and continuing education to keep learning. When you graduate, it is
easy to recognize that there is so much more to learn. However, once people get
more comfortable with their role as a professional social worker, it can be easy to
stay in your comfort zone and just do what you do without challenging yourself to
incorporate new or different knowledge and skills into your work.
• Stay balanced. Social work provides ample opportunities to work directly with
clients, take on administrative roles, address unjust policies, and much more. We
have found that having a balance of different roles, tasks, and challenges keeps us
energized. We have both had times when we were solely doing direct service with
clients. While this work was rewarding, it was also tiring. We both felt the need to
incorporate different roles and activities in our work, such as providing supervision
or an in-​service training for our agency. If you can, try to diversify your work,
which also includes your caseloads if you are working directly with clients. As
much as you can, try to work with clients who present with a variety of issues and
needs. Having variety in your work life is helpful in preventing compassion fatigue.
• Remember to maintain a work–​life balance. We discussed self-​care previously,
but work–​l ife balance is worthy of a separate discussion. It is important to
remember that although you are a social worker, you have other roles in life, such
as friend, partner, sibling, daughter/​son, parent, and many others. To protect
those, it is important not only to incorporate self-​care into your daily life but also
to draw boundaries around your work and personal lives. You can incorporate self-​
care into your professional day in many ways. Leaving the office at 5:00 p.m. in
order to meet a friend for dinner is not the only way to practice self-​care. Keeping a
work–​l ife balance, means taking time off, not checking work voice mails or e-​mails
when you do not need to, not discussing your work outside work hours, and trying
as much as possible to be present in your life outside work. Yes, you are important
to your clients, but you are not solely responsible for their care, and it is important
for your life to nurture and attend to the people and activities that you will have in
your life beyond your career.
• When in doubt, don’t! We stated previously in the book concerning self-​
disclosure that when in doubt, don’t. However, we believe that this phrase is
appropriate for all aspects of your work with clients. This statement is not meant
to imply that you should never do anything when you have doubts. We use the

Final Thoughts • 203

 phrase to emphasize how important it is to give yourself time to think through
your options before making a decision. For example, clients may ask you for a ride,
if you can attend a special event for them, or if you would be willing to complete a
task for them. We encourage you to take the time to think these choices through
with another before making any decision. Take your time to think through your
response.
• Be curious. One of the most important messages you can communicate to your
clients is your curiosity about their lives, their choices, their worlds, and their
wishes. Curiosity implies interest in the whole story and should be done without
judgment. Maintaining a stance of curiosity conveys an ever-​present interest in
your clients’ experience. The more you know about them, the more you will be able
to empathize and respond appropriately to their needs.
• Celebrate and acknowledge even small achievements. Social workers are
trained to look at individual and macro issues. As such, our scope of professional
interest is vast. As a result, we can become overwhelmed by the problems and
barriers in the world. Therefore, we encourage you to look for and celebrate every
change that you see in the work you do as social workers, from the large to the
small. Acknowledging and celebrating any form of change is a way to help stay
invigorated and motivated in your work. When working with client systems of
all sizes, you will often only see a small part of a larger arc of change and growth.
In many ways, it can feel like walking into a movie in the middle or losing a book
before you finish it. We do not always get to see how the story turns out or what
came before our work. Celebrating the small steps and accomplishments helps
validate these important milestones toward the larger goals.
• Be proud to be a social worker. You may find that when you meet different
social workers in the field, they introduce themselves by their role versus their
profession (i.e., a therapist versus a clinical social worker). By using other labels to
describe their role, these social workers are not acknowledging our profession and
providing the opportunity for others to learn about our profession and all of the
diverse roles of social workers. We always introduce ourselves as social workers,
even though much of our professional lives has been spent “doing psychotherapy.”
We could easily say that we are therapists or professors. Yet, we both proudly
introduce ourselves as social workers. We are each proud to be one and happy to
shout from the rooftops that this is who we are.

There is much to learn in our work about the world, people, and ourselves. The work
we do as social workers is challenging, frustrating, and exhilarating. We have every hope
and expectation that you will have a fulfilling and satisfying career as a social worker.
Good luck!

204 • Moving Beyond Assessment

REFERENCES

CHAPTER 2
Burkard, A. W., Knox, S., Groen, M. Perez, M., & Hess, S. A. (2006). European American therapist self-​
disclosure in cross-​c ultural counseling. Journal of Counseling Psychology, 53(1), 15–​25.
Cameron, M. (2014). This is common factors. Clinical Social Work Journal, 42, 151–​160.
Dewane, C. J. (2006). Use of self: A primer revisited. Clinical Social Work Journal, 34, 543–​558.
Dombo, E. A., & Gray, C. G. (2013). Engaging spirituality in addressing vicarious trauma in clinical social
workers: A self-​care model. Social Work & Christianity, 40(1), 89–​104.
Edwards, J. K., & Bess, J. M. (1998). Developing effectiveness in the therapeutic use of self. Clinical Social
Work Journal, 26(1), 89–​105.
Figley, C. R. (1999). Compassion fatigue: Toward a new understanding of the costs of caring. In
B. H. Stamm (Ed.), Secondary traumatic stress: Self-​care issues for clinicians, researchers, and educators
(2nd ed., pp. 3–​28). Lutherville, MD: Sidran Press.
Graybeal, C. (2014). The art of practicing with evidence. Clinical Social Work Journal, 42, 116–​122.
Katz, J. M. (2003). Tales of a therapist: Unexpected self-​d isclosure in couple therapy. Journal of Couple &
Relationship Therapy, 2(1), 43–​6 0.
Mackey, R. A., & Mackey, E. F. (1993). The value of personal psychotherapy to clinical practice. Clinical
Social Work Journal, 21(1), 97–​110.
Mahoney, M. J. (2003). Constructive psychotherapy: A practical guide. New York, NY: Guilford Press.
McCracken, S., & Marsh, J. (2008). Practitioner expertise in evidence-​based practice decision making.
Research on Social Work Practice, 18, 301–​310. doi:10.1177/​1049731507308143
Meichenbaum, D. (2007). Self-​care for trauma psychotherapists and caregivers: Individual social and organiza-
tional interventions. Melissa Institute Conference, Miami, FL.
Richardson, J. I. (2001). Guidebook on Vicarious Trauma: Recommendations Solutions for Anti-​V iolence
Workers. Centre for Research on Violence Against Women. Ontario, Canada: Author.
Safran, J. D. (2011). Theodor Reik’s Listening With the Third Ear and the role of self-​a nalysis in contempo-
rary psychoanalytic thinking. Psychoanalytic Review, 98, 205–​216.
Schneider, D. A., & Grady, M. D. (2015). Conscious and unconscious use of self: An evolutionary process.
Psychoanalytic Social Work, 22(1), 52–​70.
Stamm, B. H. (2002). Measuring compassion satisfaction as well as fatigue: Developmental history
of the Compassion Satisfaction and Fatigue Test. In C. R. Figley (Ed.), Treating compassion fatigue.
Psychosocial stress series, no. 24 (pp. 107–​119). New York, NY: Brunner-​R outledge
Trippany, R. L., Kress, V. E. W., & Wilcoxon, S. A. (2004). Preventing vicarious trauma: What coun-
selors should know when working with trauma survivors. Journal of Counseling and Development,
82, 31–​37.

CHAPTER 3
Blow, A., Davis, S., & Sprenkle, D. (2012). Therapist–​worldview matching: Not as important as matching to
clients. Journal of Marital and Family Therapy, 38(1), 13–​17.
Bryan, L. A., Dersch, C., Sterling, S., & Aredondo, R. (2004). Therapy outcomes: Client perception and
similarity with therapist view. The American Journal of Family Therapy, 32(1), 11–​2 6.
Coleman, D. (2006). Therapist–​client five-​factor personality similarity: A brief report. Bulletin of the
Menninger Clinic, 70, 232–​2 41.
Corneau, S., & Stergiopoulos, V. (2012). More than being against it: Anti-​racism and anti-​oppression in
mental health services. Transcultural Psychiatry, 49, 261–​282.
Dybicz, P. (2010). Confronting oppression not enhancing functioning: The role of social workers within
postmodern practice. Journal of Sociology & Social Welfare, 37(1), 23–​47.
Erdur, O., Rude, S., & Baron, A. (2003). Symptom improvement and length of treatment in ethnically simi-
lar and dissimilar client–​t herapist pairings. Journal of Counseling Psychology, 50(1), 52–​58.
Farsimadan, F., & Draghi-​L orenz, R. (2007). Process and outcome of therapy in ethnically similar and
dissimilar therapeutic dyads. Psychotherapy Research, 17, 567–​575.
Hall, J., Guterman, D., Lee, H., & Little, S. (2002). Counselor–​client matching on ethnicity, gender, and
language: Implications for counseling school-​aged children. North American Journal of Psychology, 4,
367–​381.
Lee, E. (2011). Clinical significance of cross-​c ultural competencies (CCC) in social work practice. Journal
of Social Work Practice, 25, 185–​2 03.
Murphy, M., Faulkner, R., & Behrens, C. (2004). The effect of therapist–​client racial similarity on client
satisfaction and therapist evaluation of treatment. Contemporary Family Therapy, 26, 279–​292.
Perez Foster, R. (1999). An intersubjective approach to cross-​c ultural clinical work. Clinical Social Work
Journal, 26, 269–​291.
Rosenblum, K., & Travis, T. M. C. (2008). The meaning of difference: American constructions of race, sex and
gender, social class, sexual orientation, and disability. New York, NY: McGraw Hill.
Safran, J. D. (2000). Resolving therapeutic alliance ruptures: Diversity and integration. Journal of Clinical
Psychology, 56, 233–​2 43.
Schmitz, C. L., Stakeman, C., & Sisneros, J. (2001). Educating professionals for practice in a multicultural
society: Understanding oppression and valuing diversity. Families in Society, 82, 612–​622.
Smith, L., Li, V., Dykema, S., Hamlet, D., & Shellman, A. (2013). Honoring somebody that society doesn’t
honor: Therapists working in the context of poverty. Journal of Clinical Psychology, 69, 138–​151.
Spencer, M. (2008). A social worker’s reflections on power, privilege, and oppression. Social Work, 53,
99–​101.
Taber, B., Leibert, T., & Agaskar, V. (2010). Relationships among client–​t herapist personality congruence,
working alliance, and therapeutic outcome. Psychotherapy, 48, 376–​380.
Williams, E., & Barber, J. (2004). Power and responsibility in therapy: Integrating feminism and multicul-
turalism. Journal of Multicultural Counseling and Development, 32, 390–​4 01.

206 • References
Yoon, E., Moulton, J., Jeremie-​Brink, G., & Hansen, M. (2012). Own group oppression, other group oppres-
sion, and perspective taking. International Journal for the Advancement of Counseling, 35, 203–​215.
Walker, R., & Staton, M. (2000). Multiculturalism in social work ethics. Journal of Social Work Education,
36, 449–​4 63.
Williams, D., & Levitt, H. (2008). Clients’ experiences of difference with therapists: Sustaining faith in
psychotherapy. Psychotherapy Research, 18, 256–​270.
Williams, E., & Barber, J. (2004). Power and responsibility in therapy: Integrating feminism and multicul-
turalism. Journal of Multicultural Counseling and Development, 32, 390–​4 01.
Zane, N., Sue, S., Chang, J., Huang, J., Lowe, S., Srinivasan, S., . . . Lee, E. (2005). Beyond ethnic
match: Effects of client–​t herapist cognitive match in problem perception, coping orientation, and ther-
apy goals on treatment outcomes. Journal of Community Psychology, 33, 569–​585.

CHAPTER 4
Bogo, M. (2006). Social work practice: Concepts, processes, and interviewing. New York, NY: Columbia
University Press.
Carroll, L. (1962). Alice’s adventures in wonderland. Harmondsworth, Middlesex: Penguin. (Original
work published 1865)
Duncan, B. L. (2010). Prologue: Saul Rosenzweig: The founder of common factors. In B. L. Duncan,
S. D. Miller, B. E. Wampold, & M. A. Miller (Eds.), The heart and soul of change (2nd ed., pp. 3–​22).
Washington, DC: American Psychological Association.
Gambrill, E. (2013). Social work practice: A critical thinker’s guide (3rd ed.). New York, NY: Oxford
University Press.
Hepworth, D. H., Rooney, R. H., Dewberry-​R ooney, G., & Strom-​Gottfried, K. (2013). Direct social work
practice: Theory and skills (9th ed.). Belmont, CA: Brooks/​Cole.
Hubble, M. A., Duncan, B. L., Miller, S. D., & Wampold, B. E. (2010). Introduction. In B. L. Duncan,
S. D. Miller, B. E. Wampold, & M. A. Miller (Eds.), The heart and soul of change (2nd ed., pp. 49–​82).
Washington, DC: American Psychological Association.
Kirsch, I. (1985). Response expectancy as a determinant of experience and behavior. American Psychologist,
40, 1189–​1202. doi:10.1037/​0 003-​0 66X.40.11.1189
Lambert, M. J., & Barley, D. E. (2002). Research summary on the therapeutic relationship and psychother-
apy outcome. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and
responsiveness to patients (pp. 17–​36). New York, NY: Oxford University Press.
Teyber, E., & McClure, F. H. (2011). Interpersonal process in therapy: An integrative model (6th ed.). Belmont,
CA: Brooks/​Cole Publishing Company.
Walsh, J. (2013). Theories for direct social work practice (3rd ed.). Belmont, CA: Thompson Brooks/​Cole.
Wampold, B.E. (2010). The basics of psychotherapy: An introduction to theory and practice. Washington,
DC: American Psychological Association.
Weinberger, J., & Rasco, C. (2007). Empirically supported common factors. In S. G. Hofmann &
J. Weinberger (Eds.), The art and science of psychotherapy (pp. 103–​129). New York, NY: Routledge.

CHAPTER 6
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Washington, DC: Author.

References • 207
Berry, K. (2011). The ethnographic choice: Why ethnographers do ethnography. Cultural Studies—​Critical
Methodologies, 11, 165–​177.
Bisman, C. (1994). Social work practice: Cases and principles. San Francisco, CA: Thompson Brooks Cole.
Corcoran, J., & Walsh, J. M. (2014). Mental health in social work: A casebook on diagnosis and strengths based
assessment (2nd ed.). Boston, MA: Pearson.
Drisko, J. W., & Grady, M. D. (2012). Evidence-​based practice in clinical social work: Essential clinical social
work series. New York, NY: Springer Science+Business Media, LLC.
Forsey, M. G. (2010). Ethnography as participant listening. Ethnography, 11, 558–​572.
Fraser, M., Richman, J., & Galinsky, M. (1999). Risk, protection, and resilience: Towards a conceptual
framework for social work practice. Social Work Research, 23(3), 131–​144.
Gambrill, E. (2013). Social work practice: A critical thinker’s guide (3rd ed.). New York, NY: Oxford
University Press.
Haight, W., Kayama, M., & Korang-​Okrah, R. (2014). Ethnography in social work practice and policy.
Qualitative Social Work, 13(1), 127–​143.
Heller, N. R., & Gitterman, A. (2011). Introduction to social problems and mental health/​illness. In N.
R. Heller & A. Gitterman (Eds.), Mental health and social problems: A social work perspective (pp. 1–​17).
New York, NY: Routledge.
Hutchison, E. (2013). Essentials of human behavior: Integrating person, environment, and the life course.
Thousand Oaks: Sage Publications.
Karls, J. M., & O’Keefe, M. (2008). Person-​in-​environment system manual (2nd ed.). Washington,
DC: NASW Press.
Kline, P. (2013). Handbook of psychological testing (2nd ed.). New York, NY: Routledge.
Kondrat, M. E. (2008). Person-​i n-​environment. In T. Mizrahi & L. E. Davis (Eds.-​i n-​Chief), Encyclopedia
of social work (20th ed., pp. 348–​354). Washington, DC, and New York, NY: NASW Press and Oxford
University Press.
Lambert, M. C., Rowan, G. T., Kim, S., Rowan, S. A., An, A. S., Kirsh, E. A., & Williams, O. (2005).
Assessment of behavioral and emotional strengths in Black children: Development of the
Behavioral Assessment for Children of African Heritage (BACAH). Journal of Black Psychology,
31, 321–​351.
Lambert, M. C., Markle, F., & Bellas, V. F. (2001). Psychopathology and assessment in African American
children and families: A historical, ecological, and strength-​based perspective. In A. Neal-​Barnett,
J. Contreras, & K. A. Kerns (Eds.), Forging links: A clinical developmental understanding of African
American children (pp. 1–​2 6). Westport, CT: Prager.
Lee, S., & Kleinman, A. (2007). Are somatoform disorders changing with time? The case of neurasthenia in
China? Psychosomatic Medicine, 69, 846–​8 49.
Leigh, J. W. (1998). Communicating for cultural competence. Toronto, Canada: Allyn and Bacon.
PDM Task Force. (2006). Psychodynamic diagnostic manual. Silver Spring, MD: Alliance of Psychoanalytic
Organizations.
Probst, B. (2013). “Walking the tightrope”: Clinical social workers’ use of diagnostic and environmental
perspectives. Clinical Social Work Journal, 41, 184–​191.
Riemann, G. (2005). Ethnographies of practice—​practising ethnography: Resources for self-​reflective
social work. Journal of Social Work Practice, 19(1), 87–​101.
Saleeby, D. (2012). The strengths perspective in social work practice (6th ed.). Boston, MA: Pearson.
Sheafor, B. W., & Horejsi, C. R. (2011). Techniques and guidelines for social work practice (9th ed.). Boston,
MA: Pearson.
Wakefield, J. C. (2013). DSM-​5 and clinical social work: Mental disorder and psychological justice as goals
of clinical intervention. Clinical Social Work Journal, 41, 131–​138.

208 • References
World Health Organization. (1992). The ICD-​10 classification of mental and behavioral disorders: Clinical
descriptions and diagnostic guidelines. Geneva, Switzerland: Author.
World Health Organization. (2014). Mental health: Strengthening our response. Fact sheet no. 220. Retrieved
from http://​w ww.who.int/​mediacentre/​factsheets/​fs220/​en/​

CHAPTER 7
Courtois, C. A., & Ford, J. D. (2012). Treatment of complex trauma: A sequenced, relationship-​based approach.
New York, NY: Guilford Press.
Cunningham, M. (2012). Integrating spirituality in clinical social work practice: Walking the labyrinth. Boston,
MA: Pearson.
Drake, R. E., & Mueser, K. T. (2000). Psychosocial approaches to dual diagnosis. Schizophrenia Bulletin,
26,105–​118.
Farmer, R. L. (2014). Interface between psychotropic medications, neurobiology, and mental illness. Smith
College Studies in Social Work, 84, 255–​272.
Heller, N. R., & Gitterman, A. (Eds.). (2011). Mental health and social problems: A social work perspective.
New York, NY: Routledge.
Jamison, K. R. (1999). Night falls fast: Understanding suicide. New York, NY: Knopf.
Tanner, T. B., Wilhelm, S. E., Rossie, K. M., & Metcalf, M. P. (2012). Web-​based SBIRT skills training for
health professional students and primary care providers. Substance Abuse, 33(3), 316–​320.
Walsh, B. W. (2006). Treating self-​injury: A practical guide. New York, NY: Guilford Press.
Witkiewitz, K., & Marlatt, G.A. (2004). Relapse prevention for alcohol and drug problems. American
Psychologist, 59(4), 224–​235.

CHAPTER 8
Ainsworth, F. (2002). Mandatory reporting of child abuse and neglect: Does it really make a difference?
Child and Family Social Work, 7, 57–​63.
Antle, B., Barbee, A., Yankeelov, P., & Bledsoe, L. (2010). A qualitative evaluation of the effects of man-
datory reporting of domestic violence on victims and their children. Journal of Family Social Work,
13, 56–​73.
Bennice, J. A., Resick, P. A., Mechanice, M., & Astin, M. (2003). The relative effects of intimate partner
physical and sexual violence on post-​t raumatic stress disorder symptomatology. Violence and Victims,
18(1), 87–​94.
Briere, J., & Elliott, D.M. (2003). Prevalence and symptomatic sequelae of self-​reported childhood phys-
ical and sexual abuse in a general population sample of men and women. Child Abuse and Neglect, 27,
1205–​1222.
Cox, L., & Speziale, B. (2009). Survivors of stalking: Their voices and lived experiences. Affilia, 24(1), 5–​18.
Dass-​Brailsford, P. (2007). A practical approach to trauma: Empowering interventions. Thousand Oaks,
CA: Sage.
Donovan, K., & Regehr, C. (2010). Elder abuse: Clinical, ethical, and legal considerations in social work
practice. Clinical Social Work Journal, 38, 174–​182.
Jamison, K. R. (1999). Night falls fast: Understanding suicide. New York: Knopf.

References • 209
Jobes, D. A., Rudd, M. D., Overholser, J. C., & Joiner, T. E. (2008). Ethical and competent care of sui-
cidal patients: Contemporary challenges, new developments, and considerations for clinical practice.
Professional Psychology: Research and Practice, 39(4), 405–​413.
Lawson, D. M. (2009). Understanding and treating children who experience interpersonal maltreat-
ment: Empirical findings. Journal of Counseling & Development, 87(2), 204–​215.
Meloy, J. R., Davis, B., & Lovette, J. (2001). Risk factors for violence among stalkers. Journal of Threat
Assessment, 1(1), 3–​16.
National Association of Social Workers. (2008). Code of Ethics. Available from: http://​w ww.socialworkers.
org/​pubs/​code/​code.asp
Reamer, F. G. (2005). Documentation in social work: Evolving ethical and risk—​management standards.
Social Work, 50(4), 325–​334.
Reamer, F. G. (2006). Ethical standards in social work (2nd ed.). Washington, DC: NASW Press.
Sinwelski, S. A., & Vinton, L. (2001). Stalking: The constant threat of violence. Affilia, 16(1), 46–​65.
Spinazzola, J., Ford, J. D., Zucker, M., van der Kolk, B. A., Silva, S., Smith, S. F., & Blaustein, M. (2005).
National survey evaluates complex trauma exposure, outcome, and intervention among children and
adolescents. Psychiatric Annals, 35, 433– ​439.
Spitz, M. (2003). Stalking: Terrorism at our doors—​How social workers can help victims fight back. Social
Work, 48(4), 504–​512.
Tower, L. E. (2003). Domestic violence screening: education and institutional support correlates. Journal of
Social Work Education, 39(3), 479–​494.
Tufford, L., Mishna, F., & Black, T. (2010). Mandatory reporting and child exposure to domestic vio-
lence: Issues regarding the therapeutic alliance with couples. Clinical Social Work Journal, 38, 426–​434.
Walsh, B. W. (2006). Treating self-​injury: A practical guide. New York, NY: Guilford Press.
Webster, S. W., O’Toole, R. O., O’Toole, A. W., & Lucal, B. (2005). Overreporting and underreporting of
child abusers: Teachers’ use of professional discretion. Child Abuse and Neglect, 29, 1281–​1296.
Zellman, G. L., & Fair, C. C. (2002). Preventing and reporting abuse. In J. E. B Meyers, L. A. Berliner, J.
N. Briere, C. T. Hendrix, T. S. Reid, & C. A. Jenny (Eds.), The APSAC Handbook on Child Maltreatment
(2nd ed., pp. 449–​476). Thousand Oaks, CA: Sage.

CHAPTER 9
de Becker, G. (1999). The gift of fear and other survival signals that protect us from violence. New York, NY: Dell.
Harkey, J. (n.d.). Be careful: Personal safety for social workers. Billerica, MA: CEU School.
Jongsma, A. E. (2004). The suicide and homicide risk assessment and prevention treatment planner. New York,
NY: Wiley.
National Association of Social Workers. (2013). Guidelines for social worker safety in the workplace.
Washington, DC: Author.
National Association of Social Workers Center for Workforce Studies. (2006). Assuring the sufficiency of a
front line workforce: A national study of licensed social workers. Washington, DC: Author.
Occupational Safety and Health Administration. (2004). Guidelines for preventing workplace violence for
health care and social service workers. Retrieved from https://​w ww.osha.gov/​P ublications/​osha3148.pdf
Shields, G., & Kiser, J. (2003). Violence and aggression directed toward human service workers: An explor-
atory study. Families in Society, 84(1), 13–​2 0.
Smith, M. (2006). Too little fear can kill you. Staying alive as a social worker. Journal of Social Work Practice,
20(1), 69–​81.

210 • References
Spencer, P., & Munch, S. (2003). Client violence toward social workers: The role of management in commu-
nity mental health programs. Social Work, 48(4), 532–​5 44.
Tapp, K., & Payne, D. (2011). Guidelines for practitioners: A social work perspective on discharging the
duty to protect. Journal of Social Work Values & Ethics, 8(2), 2–​13.
Weinger, S. (2001). Security risk: Preventing client violence against social workers. Washington,
DC: NASW Press.
Winstanley, S., & Hales, L. (2008). Prevalence of aggression towards residential social workers: Do qualifi-
cations and experience make a difference? Child Youth Care Forum, 37, 103–​110.

CHAPTER 10
Arends, I., Bruinvels, D. J., Rebergen, D. S., Nieuwenhuijsen, K., Madan, I., Neumeyer-​Gromen, A., . . .
Verbeek, J. H. (2012). Interventions to facilitate return to work in adults with adjustment disorders.
Cochrane Database of Systematic Reviews 2012, 12. Art. No.: CD006389. doi:10.1002/​14651858.
CD006389.pub2
Drisko, J. W., & Grady, M. D. (2012). Evidence-​based practice in clinical social work: Essential clinical social
work series. New York, NY: Springer Science+Business Media.
Grady, M. D., & Drisko, J. W. (2014). Thorough clinical assessment: The hidden foundation of evidence-​
based practice. Families in Society, 95(1), 5–​14. doi:10.1606/​1044-​3894.2014.95.2
Graybeal, C. (2014). The art of practicing with evidence. Clinical Social Work Journal, 42, 116–​122.
Haynes, R., Devereaux, P., & Guyatt, G. (2002). Clinical expertise in the era of evidence based medicine
and patient choice. Evidence-​Based Medicine, 7, 36–​38.
Isaac, S., & Michael, W. B. (1971). Handbook in research and evaluation. San Diego, CA: Educational and
Industrial Testing Services.
National Association of Social Workers. (2008). Code of ethics. Retrieved from https://​w ww.socialworkers.
org/​pubs/​code/​code.asp
Sackett, D., Rosenberg, W., Muir Gray, J., Haynes, R., & Richardson, W. (1996). Editorial: Evidence based
medicine: What it is and what it isn’t. British Medical Journal, 312, 71–​72.
Thyer, B. A. (1991). Guidelines for evaluating outcome studies on social work practice. Research on Social
Work Practice, 1(1), 76–​91.

CHAPTER 11
Beck J. (2011). Cognitive therapy: Basics and beyond (2nd ed.). New York, NY: Guilford Press.
Drisko, J. W., & Grady, M. D. (2012). Evidence-​based practice in clinical social work: Essential clinical social
work series. New York, NY: Springer Science+Business Media.
Goin, M. K. (2005). A current perspective on the psychotherapies. Psychiatric Services, 56, 255–​257.
Grady, M. D. (2009). Sex offenders part I: Theories and models of etiology, assessment and intervention.
Social Work in Mental Health, 7, 353–​371. doi:10.1080/​15332980802052456
Hubble, M. A., Duncan, B. L., Miller, S. D., & Wampold, B. E. (2010). Introduction. In B. L. Duncan, S.
D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change (2nd ed., pp. 23–​4 6).
Washington, DC: American Psychological Association.

References • 211
Hutchinson, E. (2013). Setting the stage: A multidimensional approach. In E. D. Hutchison (compiler),
Essentials of human behavior: Integrating person, environment, and the life course (pp. 3–​3 4). Los Angeles,
CA: Sage.
MacDonald, D., & Webb, M. (2006). Toward conceptual clarity with psychotherapeutic theories. Journal of
Psychology and Christianity, 25(1), 3–​16.
Norcross, J. C. (2002). Empirically supported therapy relationships. In J. C. Norcross (Ed.), Psychotherapy
relationships that work: Therapist contributions and responsiveness to patients (pp. 3–​16). New York,
NY: Oxford University Press.
Norcross, J. C., Hedges, M., & Castle, P. H. (2002). Psychologists conducting psychotherapy in 2001: A study
of the Division 29 membership. Psychotherapy: Theory, Research, Practice, Training, 39, 97–​102.
Prochaska, J. O., & Norcross, J. C. (1999). Systems of psychotherapy: A transtheoretical analysis (4th ed.).
New York, NY: Brooks/​Cole.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2012). Mindfulness-​based cognitive therapy for depression
(2nd ed.). New York, NY: Guilford Press.
Walsh, J. (2013). Theories for direct social work practice (3rd ed.). Belmont, CA: Thompson Brooks/​Cole.
Wampold, B. E. (2010). The basics of psychotherapy: An introduction to theory and practice. Washington,
DC: American Psychological Association.

CHAPTER 12
Bateman, A. W., & Fonagy, P. (2011). Handbook of mentalizing in mental health practice. Washington,
DC: American Psychiatric Publications.
Beck J. (2011). Cognitive therapy: Basics and beyond (2nd ed.). New York, NY: Guilford Press.
Bratton, S., Landreth, G., Kellam, T., & Blackard, S. R. (2006). CPRT package: Child parent relationship
therapy (CPRT) treatment manual: A 10-​session filial therapy model for training parents. New York,
NY: Routledge Press.
Greene, G. J., Kondrat, D. C., Lee, M. Y., Clement, J., Siebert, H., Mentzer, R. A., & Pinnell, S. R. (2006). A
solution-​focused approach to case management and recovery with consumers who have a severe mental
disability. Families in Society: The Journal of Contemporary Social Services, 87, 339–​350.
Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change (3rd ed.). New York,
NY: Guilford Press.
Norcross, J. C. (2002). Empirically supported therapy relationships. In J. C. Norcross (Ed.), Psychotherapy
relationships that work: Therapist contributions and responsiveness to patients (pp. 3–​16). New York,
NY: Oxford University Press.
Teyber, E., & McClure, F. H. (2011). Interpersonal process in therapy: An integrative model (6th ed.). Belmont,
CA: Brooks/​Cole Publishing Company.
Walsh, J. (2013). Theories for direct social work practice (3rd ed.). Belmont, CA: Thompson Brooks/​Cole.
Wampold, B. E. (2010). The basics of psychotherapy: An introduction to theory and practice. Washington,
DC: American Psychological Association.

CHAPTER 13
Deegan, P. E. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal,
11, 11–​19.

212 • References
Doran, G. T. (1981). There’s a S.M.A.R.T. way to write management’s goals and objectives. Management
Review, 70(11), 35–​36.
Hepworth, D. H., Rooney, R. H., Dewberry-​R ooney, G., & Strom-​Gottfried, K. (2013). Direct social work
practice: Theory and skills (9th ed.). Belmont, CA: Brooks/​Cole.
Meyer, P. J. (2003). What would you do if you knew you couldn’t fail? Creating S.M.A.R.T. goals. In Attitude
is everything: If you want to succeed above and beyond. Waco, TX: Meyer Resource Group.
Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change (3rd ed.). New York,
NY: Guilford Press.
Spiegler, M., & Guevremont, D. (2010). Contemporary behavior therapy. Belmont, CA: Thompson/​
Wadsworth.
Yemm, G. (2012). Essential guide to leading your team: How to set goals, measure performance and reward tal-
ent. New York, NY: Pearson Education.

CHAPTER 14
Applegate, J. S., & Bonovitz, J. M. (1995). The transitional process. In The facilitating partner-
ship: A Winnicottian approach for social workers and other helping professionals (pp. 157–​177). New York,
NY: Rowman & Littlefield.
Beck, J. (2011). Cognitive therapy: Basics and beyond (2nd ed.). New York, NY: Guilford Press.
Bogo, M. (2006). Social work practice: Concepts, processes and interviewing. New York, NY: Columbia
University Press.
Cameron, M., & Keenan, E. K. (2013). The common factors model for generalist practice. Boston, MA: Pearson.
Conner, K., & Grote, N. (2008). Enhancing the cultural relevance of empirically-​supported mental health
interventions. Families in Society: The Journal of Contemporary Social Services, 89, 587–​595. doi:10.1606/​
1044-​3894.3821
Corcoran, J. (2011). Helping skills for social work direct practice. New York, NY: Oxford University Press.
Fontes, L. A., & Plummer, C. (2010). Cultural issues in disclosures of child sexual abuse. Journal of Child
Sexual Abuse: Research, Treatment, & Program Innovations for Victims, Survivors, & Offenders, 19,
491–​518.
Gambrill, E. (2013). Social work practice: A critical thinker’s guide (3rd ed.). New York, NY: Oxford
University Press.
Hepworth, D. H., Rooney, R. H., Dewberry-​R ooney, G., & Strom-​Gottfried, K. (2013). Direct social work
practice: Theory and skills (9th ed.). Belmont, CA: Brooks/​Cole.
Kenny, J. (2008, January 28). The last session: Quitting therapy. The New Yorker. Retrieved from http://​
www.newyorker.com/​magazine/​2 008/​01/​28/​last-​session
Miley, K. K., O’Melia, M. W., & DuBois, B. L. (2013). Generalist social work practice: An empowering approach
(7th ed.). Boston, MA: Pearson.
National Association of Social Workers. (2008). Code of ethics. Washington, DC: Author.
Norcross, J. C. (2002). Empirically supported therapy relationships. In J. C. Norcross (Ed.), Psychotherapy
relationships that work: Therapist contributions and responsiveness to patients (pp. 3–​16). New York,
NY: Oxford University Press.
Ow, R., & Katz, D. (1999). Family secrets and the disclosure of distressful information in Chinese fam-
ilies. Families in Society: The Journal of Contemporary Human Services, 80, 620–​628. doi:10.1606/​
1044-​3894.1783
Shulman, L. (2012). The skills of helping individuals, families, groups, and communities (7th ed.). Belmont,
CA: Brooks/​Cole.

References • 213
Steen, C. (2001). The adult relapse prevention workbook. Branford, VT: Safer Society Press.
Wampold, B. E. (2010). The basics of psychotherapy: An introduction to theory and practice. Washington,
DC: American Psychological Association.
Xiong, Z., Tuicomepee, A., LaBlanc, L., & Rainey, J. (2006). Hmong immigrants’ perceptions of family
secrets and recipients of disclosure. Families in Society: The Journal of Contemporary Social Services, 87,
231–​239. doi:10.1606/​1044-​3894.3516
Zayas, L., Torres, L., & Cabassa, L. (2009). Diagnostic, symptom, and functional assessments of Hispanic
outpatients in community mental health practice. Community Mental Health Journal, 45, 97–​105.

CHAPTER 15
Bloom, M., Fischer, J., & Orme, J. G. (2009). Evaluating practice: Guidelines for the accountable professional
(6th ed.). Boston, MA: Allyn & Bacon.
Bringhurst, D., Watson, C., Miller, S., & Duncan, B. (2006). The reliability and validity of the
Outcome Rating Scale: A replication study of a brief clinical measure. Journal of Brief Therapy,
5(1), 23–​3 0.
Campbell, A., & Hemsley, S. (2009). Outcome Rating Scale and Session Rating Scale in psychological prac-
tice: Clinical utility of ultra-​brief measures. Clinical Psychologist, 13(1), 1–​9.
Duncan, B., Miller, S., Sparks, J., Claud, D., Reynolds, L., Brown, J., & Johnson, L. (2003). The Session
Rating Scale: Preliminary psychometric properties of a “working” alliance measure. Journal of Brief
Therapy, 3(1), 3–​12.
Engel, R. J., & Schutt, R. K. (2014). Fundamentals of social work research (2nd ed.). Los Angeles, CA: Sage.
Fischer, J., & Corcoran, K. (2013a). Measures for clinical practice and research: A sourcebook. Vol. 1: Couples,
families, and children (5th ed.). New York, NY: Oxford University Press.
Fischer, J., & Corcoran, K. (2013b). Measures for clinical practice and research: A sourcebook. Vol. 2: Adults
(5th ed.). New York, NY: Oxford University Press.
Gambrill, E. (2013). Social work practice: A critical thinker’s guide (3rd ed.). New York, NY: Oxford
University Press.
Hepworth, D. H., Rooney, R. H., Dewberry-​R ooney, G., & Strom-​Gottfried, K. (2013). Direct social work
practice: Theory and skills (9th ed.). Belmont, CA: Brooks/​Cole.
Miley, K. K., O’Melia, M., & DuBois, B. (2013). Generalist social work practice: An empowering approach (7th
ed.). Boston, MA: Allyn & Bacon
Miller, S. D., & Duncan, B. L. (2000). Outcome Rating Scale (ORS). Retrieved from: http://​w ww.scottd-
miller.com/​srs-​ors-​l icense/​
National Association of Social Workers. (2008). Code of ethics. Washington, DC: Author.

CHAPTER 16
Bennett, S., & Deal, K. H. (2009). Beginnings and endings in social work supervision: The interaction
between attachment and developmental process. Journal of Teaching in Social Work, 29(1), 101–​117.
Davis, R. T. (2010). Constructing a profession of social work: The role of social work supervision. Social
Work Review, 9(1), 20–​30.

214 • References
Harvey, A., & Henderson, F. (2013). Reflective supervision for child protection practice: Reaching beneath
the surface. Journal of Social Work Practice, 28, 343–​356.
Kim, H., Ji, J., & Kao, D. (2011). Burnout and physical health among social workers: A three-​year longitudi-
nal study. Social Work, 56(3), 258–​68.
National Association of Social Workers & Association of Social Work Boards. (2013). Best practice stan-
dards in social work supervision. Washington, DC: NASW.
Wightman, B., Weigand, B., Whitaker, K., Traylor, D., Yeider, S., & Hyden, V. (2007). Reflective practice
and supervision in child abuse prevention. Zero to Three, 28(2), 29–​33.

CHAPTER 17
Barak, A., & Grohol, J. A. (2011). Current and future trends in internet-​supported mental health interven-
tions. Journal of Technology in Human Services, 29, 155–​196.
Csiernik, R., Furze, P., Dromgole, L., & Rishchynski, G. M. (2006). Information technology and social
work: The dark side or light side? In J. M. Dunlop & M. J. Holosko (Eds.), Information technology and
evidence-​based social work practice (pp. 9–​25). Binghamton, NY: Haworth Press.
Dombo, E. A., Kays, L., & Weller, K. (2014). Clinical social work practice and technology: Personal, practi-
cal, regulatory, and ethical considerations for the 21st century. Social Work in Health Care, 53, 900–​919.
Glassgold, J. (2007). Redrawing the boundaries of psychotherapy: Is it ethically possible? PsycCritiques, 52,
978–​979.
Kolmes, K., & Taube, D. (2011). Summary of client–​therapist encounters on the web: The client experience.
Retrieved from http://​d rkkolmes.com/​research/​#therapist%20survey
Kraus, R., Stricker, G., & Speyer, C. (2011). Online counseling: A handbook for mental health professionals.
San Diego, CA: Elsevier.
McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner’s guide. New York, NY: Guilford Press.
Menon, G., & Rubin, M. (2011). A survey of online practitioners: Implications for education and practice.
Journal of Technology in Human Services, 29, 133–​141.
National Association of Social Workers. (2008). Code of ethics. Washington, DC: Author.
National Association of Social Workers & Association of Social Work Boards. (2005). NASW & ASWB stan-
dards for technology and social work practice. Retrieved from http://​w ww.socialworkers.org/​practice/​
standards/​naswtechnologystandards.pdf
Reamer, F. G. (2013). Social work in a digital age: Ethical and risk management challenges. Social Work, 58,
163–​172.
Santhiveeran, J. (2009). Compliance of social work e-​t herapy websites to the NASW code of ethics. Social
Work in Health Care, 48(1), 1–​13

CHAPTER 18
Allen, J. G. (2001). Traumatic relationships and serious mental disorders. New York, NY: Wiley.
Badenoch, B. (2008). Being a brain-​wise therapist. New York, NY: Norton.
Bennett, S., & Petrash, P. (2014). The neurobiology of substance use disorders: Information for assessment
and clinical treatment. Smith College Studies in Social Work, 84, 273–​291.

References • 215
Bentley, K. J. (2010). Psychiatric medications and meaning-​making in a residential program for adults with
serious mental illness. Qualitative Social Work, 9, 479–​499.
Bentley, K. J., & Walsh, J. (2006). The social worker and psychotropic medication (3rd ed.). New York,
NY: Brooks/​Cole.
Bentley, K. J., Walsh, J., & Farmer, R. (2005). Referring clients for psychiatric medication: Best practices for
social workers. Best Practices in Mental Health, 1(1), 59–​71.
Cohen, M. M., Tottenham, N., & Casey, B. J. (2013). Translational developmental studies of stress on brain
and behavior: Implications for adolescent mental health and illness?. Neuroscience, 249, 53–​62.
Drake, R. E., & Mueser, K. T. (2000). Psychosocial approaches to dual diagnosis. Schizophrenia Bulletin,
26(1), 105–​118.
Fan, Y., Decety, J., Yang, C., Liu, J., & Cheng, Y. (2010). Unbroken mirror neurons in autism spectrum dis-
order. Journal of Child Psychology and Psychiatry, 51, 981–​988.
Farmer, R. L. (2009). Neuroscience and social work practice. Thousand Oaks, CA: Sage.
Farmer, R. L. (2014). Interface between psychotropic medications, neurobiology, and mental illness. Smith
College Studies in Social Work, 84, 255–​272.
Farmer, R. L., Bentley, K. J., & Walsh, J. (2006). Advancing social work curriculum in psychopharmacology
and medication management. Journal of Social Work Education, 42, 211–​229.
Garland, E. L., & Howard, M. O. (2009). Neuroplasticity, psychosocial genomics, and the biopsychosocial
paradigm in the 21st century. Health & Social Work, 34(3), 191–​199.
Ivey, A. E., & Zalaquett, C. P. (2011). Neuroscience and counseling: Central issue for social justice leaders.
Journal for Social Action in Counseling and Psychology, 3(1), 103–​116.
Matto, H. C., & Strolin-​Goltzman, J. (2010). Integrating social neuroscience and social work: Innovations
for advancing practice-​based research. Social Work, 55, 147–​156.
Montgomery, A. (2002). Converging perspectives of dynamic theory and evolving neurobiological knowl-
edge. Smith College Studies in Social Work, 72, 178–​196.
Ruiz, P. (2000). Ethnicity and psychopharmacology: Review of psychiatry series, Vol. 19.
London: Eurospan Group.
Schore, A. N. (2001). The effects of early relational trauma on right brain development, affect regulation,
and infant mental health. Infant Mental Health Journal, 22(1–​2), 201–​2 69.
Siegel, D. (2003). An interpersonal neurobiology of psychotherapy: The developing mind and the resolu-
tion of trauma. In M. Soloman & D. Siegel (Eds.), Healing trauma: Attachment, mind, body, and brain
(pp. 1–​56). New York, NY: Norton.
Siegel, D., (2007). The mindful brain. New York, NY: Norton.
Weber, D. A., & Reynolds, D. R. (2004). Clinical perspectives on neurobiological effects of psychological
trauma. Neuropsychology Review, 14, 115–​129.

216 • References
INDEX

Note: Page numbers followed by italicized letters indicate figures or tables.

abuse standardized instruments, 58–​59

identifying in clients, 75–​76 of worker’s personal safety, 84–​87
asking clients difficult questions 65 of workplace safety, 87–​88
agencies, defining role within, 32–​33 Association of Social Work Boards (ASWB), 173
antianxiety medications, 200 assumptions vs. facts, in assessment, 52
antidepressants, 200
antipsychotics, 200 Bogo, M., termination process, 151
assessment bonds between social worker and client, 36
balancing strengths and pathology, 54 boundaries
bio-​psycho-​social-​spiritual framework of, maintaining personal boundaries, 203–​204
50–​52, 51t supervision process, 179
classification systems used in, 60–​61 termination process, 155
of client safety use of technology, 185–​186, 187
and assisting with client well-​being, 82 brain
identifying abuse or neglect, 75–​76 anatomy and physiology of, 192–​193
intimate partner violence, 76–​78 brainstem, 192
mandated reporting, 73–​75, 81 plasticity of, 193, 194
stalking, 76, 78–​79 see also neurobiology
suicide and self-​harming behaviors, 80–​81 burnout, impact of, 14–​15
dynamics of, 61–​62
ethnographic interviewing, 54–​56 caller identification, and client confidentiality, 185
and evidence-​based practice, 97–​98 case theories, used by social workers, 107–​108
gathering facts for, 53–​54 celebrations with clients
linking theory, assessment, and intervention, of achievement, 204
111–​112, 112f termination process, 155–​157
for potential harm to others, 88–​90 cerebral cortex, definition of, 192
checklist, 91 change
psychological testing, 60 client resistance to, 133
screening tools, 56–​59 planning for change and setting goals,
mental status exam, 57–​58 135–​144, 141t
social functioning pictograms, 57 engaging with and motivating clients, 136–​137
change (cont.) working alliance, 35–​36, 37
flexibility in, 144 taking the perspective of, 24
guidelines for, 138–​140 technology and social media use, 187
and initiating termination process, 148–​149 voluntary vs. mandated services, 47
modality used, 142 closing statement, in interviewing, 56
necessary tasks, 143 code of ethics, NASW
SMART format, 137–​138, 143 duration of treatment, 149
using objectives, 140, 142 evaluating progress, 161
charts mandated reporting, 75
linking patterns to presenting concerns, 128t, 129t personal boundaries, 155
pattern identification, 125–​126, 126t, 127t private conduct, 186
Child-​Parent Relationship Therapy, 124 professionalism, 8
classification systems used in assessment, 60–​61 social and political action, 186
client-​centered practice, 102–​103 use of social media, 184–​187
clients use of technology, 184
answering personal questions from, 11–​12 cognitive and-​behavioral theories
assessing for potential harm to others, 88–​90, 91 overview of, 119
assessing safety of and patterns of behavior, 131
assisting with well-​being, 82 collaboration
identifying abuse or neglect, 75–​76 with client in treatment planning, 99–​100
intimate partner violence, 76–​78 in goal setting, 136–​137, 138–​139
mandated reporting, 73–​75, 81 in termination process, 156
stalking, 76, 78–​79 common factors, and social worker-​client
suicide and self-​harming behaviors, 80–​81 relationship, 34–​35
charting, 126 communication, and the professional self, 7
de-​escalation techniques with, 86–​87 compassion fatigue, impact of, 14
developing interaction with, 1–3 compassion satisfaction, impact of, 15
honoring value system of, 25 conceptual syncretism, 113, 114
impact of clients’ technology use on personal confidentiality
boundaries, 185–​186 and establishing trust with clients, 44
initial session with and use of technology and social media, 184–​185
attending to paperwork, 45 conflict, de-​escalation techniques for, 86–​87
creating a safe environment, 43 Constructive Psychotherapy: A Practical Guide
establishing a trusting relationship, 44–​45 (Mahoney), 13
preparation for, 41–​43 continuing education, 203
recognizing differences among clients, 47–​48 Corcoran, K., Measures for Clinical Practice and
setting the framework for sessions, 45–​47 Research, 163
ten tips on preparing for, 48 cover terms, in assessment, 55–​56
asking clients difficult questions critical analysis
myths and facts about difficult questions, 64–​65 of published research, 104–​106
purpose of asking difficult questions, 63–​64, 70 when learning a theory, 116
suggestions regarding difficult cultural issues in practice, 21–​28
questions, 66–​70 commonalities with clients, recognizing and
recognizing similarities with, 25–​26 working with, 25–​26
resistance to change, 133 client value systems, honoring, 25
retaining focus on, 10 cultural or religious symbols, display of, 46
role of social worker with, 12–​13 maintaining awareness of, 27–​28
self-​disclosure to, 26–​27, 203–​204 power and oppression
social worker-​client relationship, 33–​37 addressing issues of, 23–​24
common factors, 34–​35 client experiences of, 21–​23
“dodo bird verdict,” 33–​34 self-​assessments, links to, 28
resource guide, 37–​38 and self-​disclosure, 26–​27
significance of, 36–​37 and standardized instruments in assessment, 59

218 • Index
 use of classification systems in assessment, 61 methods for evaluating achievement, 159–​160,
use of technology and social media, 185 159t, 160t
curiosity, maintaining, 204 rationale for, 158–​159
using objective measures, 160–​166
danger, somatic signals of, 86, 88 Single-​System Designs (SSD), 163–​166,
data collection, guidelines for critical analysis of, 165f
105–​106 standardized instruments, 161–​163,
“Dead Person” rule in goal setting, 139 162t, 163t
de-​escalation techniques, and personal safety, using subjective measures, 160–​161
86–​87 Goal-​Attainment Scales, 166, 166t
descriptors, client use of, 56 Self-​Anchored Scales, 166–​167, 167t
Dewberry-​Rooney, G., social work roles, 29, 30t Session-​Monitoring Scales, 167–​168
Diagnostic and Statistical Manual of Mental Disorders, evidence-​based practice
Fifth Edition (DSM-​5), 60, 61 with client-​centered practice, 102–​103
Direct Social Work Practice: Theory and Skills defining, 96
(Hepworth et al.), 30t limitations of, 101–​102
discharge summary, 156–​157 major theories used, 118–​121
discrimination and modalities used, 142
addressing issues of, 23–​24 role of theory in, 114–​115
increasing awareness of in practice, 22–​23 sources of information for, 103–​104
maintaining awareness of in practice, 27–​28 use in treatment planning
dissociation, function of, 193–​194 collaborating with client, 99–​100
diversity, approaching and valuing, 202 creating a treatment plan, 100
“dodo verdict,” 33–​34 defining, 96
Dombo, E. A., use of technology to deliver developing new patterns of behavior,
services, 188 132–​133
Doran, G. T., SMARTR goals, 138 evaluating information, 99
dress and physical presentation, professional sense guidelines for analyzing research, 104–​106
of, 5–​6, 5t guidelines for analyzing theory, 116
Drisko, J. W., limitations of evidence-​based implementing treatment plan, 100–​101
practice, 101 learning to use, 95–​96
dual diagnosis, 67 patient assessment, 97–​98
searching for information, 98–​99
eclectic approach to therapy, 113, 114 see also evaluating practice
ecomap, use in assessment, 57 explanatory theories, as used by social workers,
emotional self-​care, assessing, 18 108–​109
empirically supported interventions, 109 extratherapeutic factors, 34
endorsements, requesting from clients, 187
environment, creating a safe, 43 Facebook
Erickson, Milton, 13 personal use by professionals, 186
ethics increasing use of, 183
NASW code of ethics facts
duration of treatment, 149 framework for gathering, 53–​54
evaluating progress, 161 vs. assumptions, 52
mandated reporting, 75 families, using genograms in assessment, 57
personal boundaries, 155 family theories and models, significance of, 113
private conduct, 186 feedback
professionalism, 8 providing feedback, 6–​7
social and political action, 186 receiving in supervision, 177–​179
use of social media, 184–​187 Fischer, J., Measures for Clinical Practice and
use of technology, 184 Research, 163
ethnographic interviewing, 54–​56 flexibility, in planning for change and setting
evaluating practice goals, 144

Index • 219
Gambrill, E. and use of technology to deliver services, 188
methods for evaluating achievement, 159 integrated approach to therapy, 113, 114
reviewing standardized measures, 162, 163t interdisciplinary teams, working with, 6–​7
social work roles and functions, 31 International Classification of Diseases, Tenth Revision
genogram, use in assessment, 57 (ICD-​10), 60, 61
global questions, in assessment, 55 interventions
Goal-​Attainment Scales, 166 common factors in, 34–​35
goals definitions of, 109–​110
methods for evaluating achievement, 159–​160, empirically supported interventions, 109
159t, 160t and evidence-​based practice, 114–​115
planning for change and setting goals, collaborating with client, 99–​100
135–​144, 141t creating a treatment plan, 100
engaging with and motivating clients, 136–​137 defining evidence-​based practice, 96
flexibility in, 144 evaluating information, 99
guidelines for, 138–​140 guidelines for analyzing research, 104–​106
and initiating termination process, 148–​149 implementing treatment plan, 100–​101
modality used, 142 learning to use research, 95–​96
necessary tasks, 143 patient assessment, 97–​98
and the SMART format, 137–​138, 143 searching for information, 98–​99
using objectives, 140, 142 sources of information for, 103–​104
setting specific goals, 160 guidelines for critical analysis of, 105
and social worker-​client alliance, 36 learning and applying theories for, 112–​114,
Grady, M. D., limitations of evidence-​based 115–​116, 116–​117
practice, 101 linking theory, assessment, and intervention,
grand theories, used by social workers, 1–​9 111–​112, 112f
“Guidelines for Evaluating Outcome Studies.” major theories used in practice, 118–​121
(Thyer), 104–​106 the middle phase of treatment
developing new patterns, 132–​133
Handbook in Research and Evaluation (Isaac & explaining patterns, 130–​132
Michael), 104–​106 linking patterns to presenting concerns,
Haynes, R., definition of evidence-​based medicine, 96 128–​130, 128t, 129t
Health and Psychological Instruments (HAPI) and pattern identification, 124, 125–​128, 126t, 127t
database, 162–​163 using charts, 125–​126
Health Insurance Portability and Accountability Act using journaling, 126–​128
of 1996 (HIPAA), 185 interviewing, ethnographic, 54–​56
Hepworth, D. H., social work roles, 29, 30t intimate partner violence
honesty, practicing, 202 assessing for, 75–76
humility, practicing, 202 definition of, 77
Hutchinson, E., guidelines for analyzing theory, 116 and mandated reporting, 76–​78
introductions, at first client session, 42
identity issues in practice, 21–​28 Isaac, S., Handbook in Research and Evaluation,
commonalities with clients, recognizing and 104–​106
working with, 25–​26
client value systems, honoring, 25 Jamison, Kay Redfield, Night Falls
cultural or religious symbols, display of, 46 Fast: Understanding Suicide, 80
maintaining awareness of, 27–​28 journaling, and pattern identification, 126–​128
power and oppression
addressing issues of, 23–​24 Kolmes, K., clients’ use of Internet, 187
client experiences of, 21–​23
self-​assessments, links to, 28 leadership, and responsibility for self-​care, 16
and self-​disclosure, 26–​27 life experiences, and self-​disclosure to clients, 26–​27
informed consent limbic system, defined, 192
and mandated reporting, 75 listening, in assessment, 55
obtaining, 45 literature, guidelines for critical analysis, 104–​106

220 • Index
MacDonald, D., conceptual syncretism, 113, 114 National Association of Social Workers (NASW)
Mahoney, M. J., Constructive code of ethics
Psychotherapy: A Practical Guide., 13 duration of treatment, 149
mandated reporting evaluating progress, 161
and client confidentiality, 44–​45 mandated reporting, 75
compiling report, 81 personal boundaries, 155
discrepancies in, 74 private conduct, 186
legal and ethical issues, 75 the professional self, 8
meaning of, 73–​74 social and political action, 186
mandated treatment, motivating clients for change, use of social media, 184–​187
136–​137 use of technology, 184
mandated vs. voluntary clients, and initial client and supervision, 173
session, 47 use of evidence-​based practice, 95–​96
marginalization, awareness of issues, 21–​23, workplace safety report, 85
23–​24, 27–​28 neglect, identifying in clients, 75–​76
Measures for Clinical Practice and Research neurobiology
(Fischer & Corcoran), 163 anatomy and physiology of the brain, 192–​193
medications defined, 191–​192
classes of, 200 significance of in client care, 193–​194
psychiatric, 195–​197 neurons
meditation, to address vicarious trauma, 19–​20 definition of, 192
Meichenbaum, D., Self-​care for Trauma mirror neurons, 193
Psychotherapists and Caregivers, 16 neuropsychological testing, use in assessment, 60
mental health neuroscience, and macro practice, 195
areas of practitioner expertise, 107 neurotransmitters, definition of, 192–​193
mental status exam, 57–​58 Night Falls Fast: Understanding Suicide
neuroscience and issues of mental health care, 195 ( Jamison), 80
World Health Organization (WHO) definition, 51
Michael, W. B., Handbook in Research and Evaluation, objective measures
104–​106 examples of, 160–​161
middle phase of treatment standardized instruments, 161–​163
developing new patterns, 132–​133 objectives
explaining patterns, 130–​132 specifying, 160
four main steps of, 124 use in planning for change, 140, 141t, 142
influence of theories and models on, 123–​124 Occupational Safety and Health Administration
linking patterns to presenting concerns, 128–​130, (OSHA), 90–​91
128t, 129t oppression and power, awareness of, 21–​23,
and pattern identification, 125–​128 23–​24, 27–​28
using charts, 125–​126, 126t, 127t oral communication, and the professional self, 7
using journals, 126–​128 organizational theories, overview of, 121
midrange theory, used by social workers, 108 Outcome Rating Scale, 167
mirror neurons, 193 outcomes, client
modality, used in planning for change and setting common factors in, 34–​35
goals, 142 the “dodo verdict,” 33–​34
models and a working alliance with clients, 35–​36
definition of, 109
influence on middle phase of treatment, 123–​124 paperwork, attending to, 45
mood stabilizers, 200 participant listening, and assessment, 55
Motivational Interviewing pathology, balancing with strengths, 54
and developing new patterns of behavior, 132 patterns’
and planning for change, 137 developing new, 132–​133
Muir Gray, J., definition of evidence-​based development and purpose of, 130–​132
medicine, 96 identifying during intervention, 124, 125–​128

Index • 221
patterns (cont.) the professional self, 8–​13
using charts, 125–​126, 126t, 127t role of the social worker, 12–​13
using journals, 126–​128 self-​awareness, 9–​10
linking to presenting concerns, 128–​130, self-​disclosure, 10–​12
128t, 129t and self-​development, 4–​8
peer support, seeking out, 202 communication, 7
personal safety, upon first meeting clients, 43 dress and physical presentation, 5–​6, 5t
person-​first approach interdisciplinary teams, working with, 6–​7
to assessment and diagnosis, 61 social media, hints for responsible use of, 189
to substance abuse issues, 67–​68 social media, impact of, 183
person-​in-​environment perspective social media, use of, 184–​186, 187
on assessment, 50, 51 see also supervision
and ecomaps, 57 psychiatric medications, in social work practice,
Person-​in-​Environment System Manual, 61 195–​197
physical abuse, questioning clients about, 65 psychiatrists
physical self-​care, assessing, 17–​18 guidelines for referral and collaboration, 199
placebo effect, of worker-​client relationship, 34 working relationships with, 197
plasticity, of the brain, 193, 194 Psychodynamic Diagnostic Manual (PDM), 60, 61
power and oppression psychodynamic theories, overview of, 118
addressing issues of, 23–​24 psychological self-​care, assessing, 18
power and oppression, awareness of issues, psychological testing, use in assessment, 60
21–​23, 27–​28 psychostimulants, 200
practice psychotropic medications, classes of, 200t
evaluation of
methods for evaluating achievement, 159–​160, questions to clients
159t, 160t difficult questions, myths and facts about, 64–​65
rationale for evaluation, 158–​159 difficult questions, purpose of asking, 63–​64, 70
using objective measures, 160–​166 difficult questions, suggestions regarding, 66–​70
Single-​System Designs (SSD), 163–​166, 165f on religion and spirituality, 68
standardized instruments, 161–​163, on self-​harm and suicide, 69–​70
162t, 163t on sexuality, 68–​69
using subjective measures, 160–​161 on substance abuse, 66–​68
Goal-​Attainment Scales, 166, 166t on trauma history, 66
Self-​Anchored Scales, 166–​167, 167t
Session-​Monitoring Scales, 167–​168 Recovery Model, and planning for change, 144
see also evidence-​based practice reflective supervision, 180–​181
neuroscience and macro practice, 195 relational theories and models
practice theories, as used by social workers, and explaining patterns of behavior, 131–​132
108–​109 significance of, 113
prefrontal cortex relationships, and use of technology, 184
and brain plasticity, 194 religion and spirituality, questioning clients
definition of, 192 regarding, 68
professional and workplace self-​care, 19 religious symbols, displayed in office, 46
professionalism research
impact of work on the individual social in client-​centered practice, 102–​103
worker, 13–​16 guidelines for critical analysis of, 104–​106
burnout, 14–​15 limitations for evidence-​based practice, 101–​102
compassion fatigue, 14 resources for, 103–​104
compassion satisfaction, 15 use in treatment planning
self-​assessment, importance of, 15 collaborating with client, 99–​100
self-​care creating a treatment plan, 100
assessing, 17–​19 defining evidence-​based practice, 96
ways to provide, 15–​16, 16t evaluating information, 99

222 • Index
 implementing treatment plan, 100–​101 identifying abuse or neglect, 75–​76
learning to use, 95–​96 intimate partner violence, 76–​78
patient assessment, 97–​98 mandated reporting, 73–​75, 81
searching for information, 98–​99 stalking, 76, 78–​79
resistance to change, 133 suicide and self-​harming behaviors, 80–​81
Resource and Summary Guides assessing for potential harm to others, 88–​90
Asking the Difficult Questions, 71–​72 assessing safety of others
Assessing Safety of Others in Relation to the checklist, 91
Client, 90–​91 workplace safety, 87–​88
Assessing the Safety of the Client, 82–​83 OSHA safety plan for mental health
Assessing Your Self-​care, 17–​19 practitioners, 90–​91
Assessment, 62 personal safety
Beginning Knowledge of the Brain and Its assessing, 84–​87
Functions, 198–​200 upon first meeting clients, 43
Evaluation of Practice, 168 in the workplace, 84–​87
The First Session, 48–​49 tips for high-​risk tasks, 87–​88
The Middle Phase of Treatment, 134 screening tools
Role of Theory in Social Work Practice, 118–​121 in assessment, 56–​59
Supervision, 182 mental status exam, 57–​58
Technology and Social Media, 189–​190 social functioning pictograms, 57
Your Role and Relationship with Your standardized instruments, 58–​59
Clients, 37–​38 secondary gains, and client ambivalence, 47–​48
Richardson, W., definition of evidence-​based secondary traumatic stress (STS)
medicine, 96 defined, 14
risk and resilience perspective, in assessment, 54 ways to protect against, 16t
rituals, and termination process, 155–​157 Self-​Anchored Scales, 166–​167, 167t
role of the social worker self-​assessment
clarity regarding, 31–​32 cultural and identity issues in practice, 28
defining within agencies, 32–​33 importance of, 15
initial session with clients self-​awareness
attending to paperwork, 45 and cross-​cultural practice, 24
creating a safe environment, 43 and feedback in supervision, 177–​179
establishing a trusting relationship, 44–​45 and personal safety, 86
preparing for, 41–​43 and realizing limits, 201–​202
recognizing differences among clients, 47–​48 and reflective supervision, 180–​181
setting the framework for sessions, 45–​47 and using the professional self, 9–​10
ten tips on preparing for, 48 self-​care
social worker-​client relationship, 33–​37 meditation to address vicarious trauma, 19–​20
common factors, 34–​35 regular practice of, 201
the “dodo verdict,” 33–​34 ways to provide, 15–​16, 16t
resource guide, 37–​38 Self-​care for Trauma Psychotherapists and Caregivers
significance of, 36–​37 (Meichenbaum), 16
the working alliance, 35–​36, 37 self-​determination, in abusive relationships, 78
and using the professional self, 12–​13 self-​disclosure
variety of roles, 29–​31, 30t sharing commonalities, 26–​27
Rooney, R. H., social work roles, 29, 30t and using the professional self, 10–​12
Rosenberg, W., defining evidence-​based self-​harming behavior
medicine, 96 and assessing client safety, 80–​81
questioning clients regarding, 65, 69–​70
Sackett, D., defining evidence-​based medicine, 96 self-​perception, and assessment process, 59
safety Session-​Monitoring Scales, 167–​168
assessing client safety Session Rating Scale, 167
and assisting with client well-​being, 82 sexual abuse, questioning clients regarding, 65

Index • 223
sexuality, questioning clients regarding, 68–​69 taking pride in, 204
shame, confronting client feelings of, 64 using technology to deliver services, 188
Single-​System Designs (SSD), 163–​166, 165f somatic signals of danger, recognizing and
skill-​based theories and models, 113 heeding, 86, 88
SMART format, 137–​138, 143 specialties, developing, 202–​203
social contexts, and use of ecomaps, 57 spiritual practices
social control, definition of, 31 meditation to address vicarious trauma, 19–​20
social functioning pictograms, use in assessment, 57 spiritual self-​care, assessing, 18–​19
social justice stalking, and mandated reporting, 76, 78–​79
and evidence-​based practice, 101 standardized instruments
social justice issues and neuroscience, 195 and evaluating practice, 161–​163, 162t, 163t
social media use in assessment, 58–​59
client use of, 187 strengths perspective, in assessment, 54
ethical implications of, 184–​187 Strom-​Gottfried, K., social work roles, 29, 30t
personal use of, 186 Structural Family Therapy, 124
professionalism and, 183 subjective measures
professional use of, 184–​186 examples of, 161
responsible use of, 189 Goal-​Attainment Scales, 166, 166t
social work substance abuse, questioning clients regarding,
advice for succeeding, 201–​204 65, 66–​68
areas of practitioner expertise, 107 suicide
duration of treatment, 148–​149 and assessing client safety, 80–​81
initial session with clients questioning clients regarding, 65, 69–​70
attending to paperwork, 45 supervision
creating a safe environment, 43 agenda for supervision session, 182
establishing a trusting relationship, 44–​45 creating time for, 172–​173
preparing for, 41–​43 feedback, receptivity to, 177–​179
recognizing differences among clients, 47–​48 length and frequency of, 172
setting the framework for sessions, 45–​47 maintaining personal boundaries in, 179
ten tips on preparing for, 48 maximizing learning opportunities in, 175–​177, 181
and issues of neuroscience and mental health, 195 purposes and tasks of, 173–​174
and psychiatric medications, 195–​197 questions to ask in, 176–​177
role of theory in reflective supervision, 180–​181
clarifying terminology, 107–​110 role in learning, 171, 181
and evidence-​based practice, 114–​115 various formats of, 174–​175, 181
learning and applying theories, 112–​114, syncretism, conceptual, 113, 114
115–​116, 116–​117 systems theories, overview of, 120
linking theory, assessment, and intervention,
111–​112, 112f tasks
major theories used in practice, 118–​121 for first meeting with client, 43
use of theories in social work, 110–​111 in planning for change and setting goals, 141t, 143
safety tips for high-​risk tasks, 87–​88 risks related to work tasks, 87–​88
social worker-​client relationship, 33–​37 and social worker-​client alliance, 35–​36
common factors, 34–​35 Taube, D., clients’ use of Internet, 187
the “dodo verdict,” 33–​34 technology
resource guide, 37–​38 and advancement of social work values, 186
significance of, 36–​37 hints for responsible use of, 189
the working alliance, 35–​36, 37 used to deliver services, 188
social work roles, 29–​31, 30t see also social media
clarity regarding, 31–​32 telehealth, 188
defining within agencies, 32–​33 telephone, use of
variety of, 29–​31 and client confidentiality, 185
as strengths-​based profession, 152 and personal boundaries, 185–​186

224 • Index
termination and evidence-​based practice
associated meanings, 147–​148 analyzing research, guidelines for, 104–​106
and first client session, 46 analyzing theory, guidelines for, 116
importance of planning for, 147 collaborating with client, 99–​100
initiating process of, 148–​149 creating a treatment plan, 100
key points to remember, 157 defining, 96
and middle phase of treatment, 123 evaluating information, 99
process of, 151–​157 implementing treatment plan, 100–​101
consolidating gains, 153 learning to use research, 95–​96
gifts, 157 patient assessment, 97–​98
maintaining personal boundaries, 155 searching for information, 98–​99
planning for next steps, 153–​154 sources of information for, 103–​104
processing emotional bonds, 154–​155 major theories used in practice, 118–​121
reviewing work, 151–​152 and middle phase of treatment, 123–​124
rituals and celebrations, 155–​157 planned and unplanned termination, 149–​151,
unplanned termination, 150–151 150t, 152t
types of, 149–​151, 150t, 152t planning for change and setting goals,
terminology, clarifying, 107–​110 135–​144, 141t
theoretical models engaging with and motivating clients, 136–​137
and client outcomes, 34–​35 flexibility in, 144
and use of self, 9 guidelines for, 138–​140
theory modality used, 142
and evidence-​based practice, 114–​115 necessary tasks, 143
guidelines for critical analysis of, 116 and the SMART format, 137–​138, 143
influence on middle phase of treatment, 123–​124 using objectives, 140, 142
major theories used in practice, 118–​121 termination process, 151–​157
role in social work practice consolidating gains, 153
clarifying terminology, 107–​110 gifts, 157
explanatory theories and practice theories, key points to remember, 157
107–​109 maintaining personal boundaries, 155
learning and applying theories, 112–​114, planned and unplanned termination, 149–​151,
115–​116, 116–​117 150t, 152t
linking theory, assessment, and intervention, planning for next steps, 153–​154
111–​112, 112f processing emotional bonds, 154–​155
use in social work practice, 110–​111 reviewing work, 151–​152
therapeutic relationship or alliance, and client rituals and celebrations, 155–​157
outcomes, 35 trust, establishing with clients, 44–​45, 46
therapist factors, and client outcomes, 35 Twitter, personal use of, 186
therapy
increasing self-​awareness in, 9–​10 use of self, 8–​13
integrated or eclectic approaches to, 113, 114
models and techniques, 34–​35 value systems, honoring, 25
the working alliance, 35–​36 vicarious trauma (VT)
Thyer, B. A., “Guidelines for Evaluating Outcome defined, 14
Studies.”, 104–​106 using meditation to address, 19–​20
trauma ways to protect against, 16t
and brain plasticity, 194 violence
and dissociation, 193–​194 assessing potential for, 88–​90
questioning clients regarding, 66 assessing for history of experiences, 75–76
vicarious trauma and secondary traumatic stress, OSHA safety plan for mental health
14, 16t practitioners, 90–​91
treatment, duration of, 148–​149 voluntary vs. mandated services, and initial client
treatment planning session, 47

Index • 225
waiting room, greeting clients in, 42 diversifying, 203
Walsh, J. impacts of on individual social
consistency between theory and intervention, 110 workers, 13–​16
theories used by social workers, 107–​108 and rewards of social work profession, 16–​17
Webb, M., conceptual syncretism, 113, 114 workplace and professional self-​care,
Wightman, B., reflective supervision, 180–​181 assessing, 19
working alliance workplace safety, assessing, 87–​88
and social worker-​client relationship, 35–​36 World Health Organization (WHO)
strengthening, 37 definition of mental health, 51
work-​life balance, maintaining, 203 International Classification of Diseases, Tenth
workload Revision (ICD-​10), 60, 61
and compassion satisfaction, 15 written communication, and the professional self, 7

226 • Index