Chapter 13 - Planning and Implementing Change-Oriented Strategies PDF

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Notes from Professor Georgena Haranis's class on planning and implementing change-oriented strategies....

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Chapter 13 - Planning and Implementing Change-Oriented Strategies ● Change-oriented approaches ○ Aimed to facilitate attainment of goals or respond to a mandate in case of involuntary clients ○ Approaches organized around systematic interpersonal and structural elements of helping process ■ Task-centered model ■ Crisis intervention model ■ Cognitive restructuring technique ■ Solution-focused brief treatment model ■ Case management practice ○ Generalist-eclectic practice ■ Person and environment focus informed by ecological theory ■ Emphasis on establishing positive helping relationship and empowerment as well as holistic multilevel assessment ● Including focus on diversity, oppression, and strengths ■ Problem-solving model that provides structure and guidelines for work with clients ■ Flexibility in use of problem-solving methods that allows a choice among range of theories based on compatibility with each client’s situation ● Planning goal attainment strategies ○ Is approach appropriate for addressing problem/service goals? ■ Does it allow for integration of environmental factors as contributing to problem, so as not to add sense of being marginalized? ■ Are modifications indicated to it’s responsive to diverse individuals, families, minors? ■ Is it flexible enough that it respects and can be adapted to specific cultural beliefs, values, and a different worldview? ■ Does it address sociopolitical climate as factor in creating/sustaining client’s problem? ■ Covert interactions - subtle acts characterized as microaggressions people are treated differently based on race, ethnicity, etc. ○ What empirical or conceptual evidence supports effectiveness of the approach? ○ Is approach compatible with basic values/ethics of social work? ■ Does the approach safeguard client’s right to self determination? ● Self-determination and minors - complicated ■ Does the approach safeguard the client’s right to informed consent? ● Informed consent and minors - informed by developmental stage, cognitive/reasoning ability ○ Am I sufficiently knowledgeable and skills in this approach to use with others? ■ Technical eclecticism - blending generalist practice ● Models and techniques of practice ● The task-centered model ○ Developed by William Reid and Laura Epstein

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Specific focus on problems of concern identified by client Emphasis on tasks and collaborative responsibilities between client and SW Tenets of task-centered approach ■ Clients are capable of solving their own problems ■ Clients’ identification of priority concerns and collaborative relationship are understood to be empowering aspects of model ○ Theoretical framework of the task-centered model ■ Action-oriented model in which problem solving activities occurred within a limited time frame ○ Evidence base and use of task-centered model ○ Utilization of task-centered model with minors ○ Application of task-centered model with diverse groups Procedures of the task-centered model ○ Developing general tasks ○ Developing specific tasks ■ 1. Assessing client readiness to engage in an agreed-upon task ■ 2. Brainstorming alternative tasks ■ 3. Establishing a reward or an incentive ○ Task implementation sequence ■ (TIS) - involves sequence of discrete steps ■ 1. Enhance client’s commitment to carry out the tasks ■ 2. Plan the details of carrying out tasks ● The practitioner’s role in task planning ● Conditions for task completion ■ 3. Analyze and resolve barriers and obstacles ■ 4. Rehearse or practice behaviors involved in tasks ● People receive information about self-efficacy from four sources ○ Performance accomplishments ○ Vicarious experience ○ Verbal persuasion ○ Emotional arousal ● Increasing self-efficacy using behavioral rehearsal, modeling, and role play ○ Behavioral reversal - intended to reduce anxieties and help clients practice new behaviors or coping patterns ○ Role-playing - most common form of behavioral reversal client able to rehearse desired behavior/outcome ● Guided practice - aid task accomplishment; observing client as they engage in task related to target behavior, provide feedback ■ 5. Summarize the task plan ○ Failure to complete tasks ■ Reasons related to specific task ● Occurrence of emergency or crisis ● Lack of commitment

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● Lack of skills/resources ● Tasks inadequately specified ● Adverse beliefs ● Lack of support ● Environmental factors ● Reactions to the practitioner ● Inadequate preparation ■ Reasons related to the target problem ● Attributed not acknowledged problems ● Conflicting wants/needs ● Client unaware of consequences ● Little hope for change ○ Monitoring progress ■ 1. Once tasks have been identified and agreed upon, devote time to review progress; document completed tasks ■ 2. During review process, if tasks are incomplete or haven’t had effect, explore barriers/obstacles and reasons; renegotiate tasks if necessary ○ Strengths and limitations of the task-centered model ■ Sustained therapeutic relationship with clients is unlikely to evolve The crisis intervention model ○ Equilibrium model - based on basic crisis theory ■ Knowledge of how to intervene with clients in crisis considered essential for skilled practice ○ Tenets of crisis intervention equilibrium model ■ Assessment involves determining ● Severity of the crisis ● Client’s current emotional status and level of mobility/immobility ● Alternatives, coping mechanisms, support systems, and other available resources ● Client’s level of lethality (specifically whether they’re a danger to self or others) ■ Triage assessment system - fast/efficient way to assess/obtain real time estimate of what is occurring with client in crisis situation ● Provides framework for SWs to ○ Assess client’s affective, behavioral, emotional functioning ○ Assess severity of situation ○ Plan appropriate intervention strategy ○ Definition of crisis ■ Perception of an event or situation as an intolerable difficulty that exceeds resources or coping mechanism of the person ■ Prolonged crisis-related stressors have potential to severely affect cognitive, behavioral, and physical functioning ○ Crisis reactions and stages ■ Crisis reaction - any event/situation that upsets client’s normal psychic

balance to extent that their sense of equilibrium is severely diminished People’s crisis reactions typically go through several stages ● Stage 1: initial tension is accompanied by shock and perhaps even denial of crisis-provoking event ● Stage 2: to reduce tension, client attempts to utilize usual emergency problem-solving skills; if skills fail to result in lessening of tension, stress level increases ● Stage 3: client experiences severe tension, feels confused, overwhelmed, helpless, angry, or acutely depressed; length of this phase varies according to nature of hazardous event, strengths and coping capacities of client, and degree of responsiveness from social support systems Duration of contact and focus ■ Guiding principles of time-limited crisis intervention ● Focus of crisis intervention is on here and now ○ No attempt made to deal with either precrisis personality dysfunction or intrapsychic conflict, but attention to symptoms may be required ● Goals limited to alleviating distress and assisting clients to regain equilibrium ● Tasks identified, and task performance intended to help clients achieve new state of equilibrium Intervening with minors ■ Two distinct crisis categories used to distinguish minor’s reaction ● Type I: single, distinct crisis experience - symptoms manifested ● Type II: result of longstanding, repeated trauma whose cumulative effects result in minor’s psyche developing defensive coping strategies, anxiety, depression, acting-out behavior ■ Triage system assessment - especially important in determining minor’s cognitions and behaviors as result of crisis ■ Interactive Trauma/Grief-Focused Model (IT-GFT) - developed by Korol, Green, and Grace; emphasizes developmental ecological framework ● Developmental stage and environment within which minor operates are interrelated ● Four attributes based on research address effects of crisis experienced and guide intervention ○ Characteristics of stressors - perception of threat, physical proximity, duration, intensity ○ Characteristics of the minor - developmental stage, gender, vulnerability, prior psychological/behavioral problems affect experience ○ Minor’s efforts to cope - good communications skills, sense of self, internal locus of control, average intelligence indicate positive outcome ■

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Characteristics of postdisaster environment - reaction strengthened by social supports from significant others and resources; can reduce stress and act as protective factors

Benefits of a crisis ■ May promote growth in aftermath of crisis ○ Theoretical framework of crisis intervention ○ Evidence base and use of crisis intervention ■ Crisis Intervention Teams (CITs) ○ Application of crisis intervention with diverse groups ○ Procedures of crisis intervention ■ Step 1: define the problem ■ Step 2: ensure client safety ■ Step 3: provide support ■ Step 4: examine alternatives ■ Step 5: make plans ■ Step 6: obtain commitment ■ Anticipatory guidance ○ Strengths and limitations of the strategy ■ Initial intervention phase has three strategic objectives ● 1. Relieve client’s emotional distress ● 2. Complete assessment of client’s cognitive, behavioral, emotional functioning ● 3. Plan strategy of intervention, focusing on relevant tasks client is able to perform Cognitive restructuring ○ Therapeutic process derived from CBT ○ Also referred to as cognitive replacement - considered to be cornerstone of cognitive behavioral approaches ○ Designed to help clients modify beliefs, faulty thought patterns or perceptions, and destructive verbalizations ■ Thereby leading to changes in behavior ○ Theoretical framework ■ Rational-emotive therapy (RET) ○ Tenets of cognitive behavioral therapy and cognitive restructuring ■ Restructuring - cognitive procedural technique aiming to change client’s thoughts, feelings, overt behaviors that contribute to problem behavior ■ CBT based on assumption that people construct own reality ■ Thinking - primary determinant of behavior and involves statements people say to or about themselves ■ Cognitions - affect behavior, manifested in behavioral responses ■ Behavioral change - involves assisting clients to make constructive change by focusing on their misconceptions and extent to which they produce or contribute to their problems ○ Cognitive distortions

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All or nothing thinking Blaming Catastrophizing Discounting positives Emotional reasoning Inability to disconfirm Judgment focus Jumping to conclusions Mind reading Negative (mental) filtering Overgeneralizations or globalization ● Labeling ■ Personalizing ■ Regret orientation ■ “Should” statements ■ Unfair comparisons ■ What ifs ○ Cognitive schemas ■ Memory patterns that a client uses to organize information; can be positive or negative ○ Empirical evidence and uses of cognitive restructuring ○ Using cognitive restructuring with minors ○ Applying cognitive restructuring with diverse groups ○ Procedures of cognitive restructuring ■ 1. Assist clients in accepting that their self-statements, assumptions, and beliefs largely determine their emotional reactions to life’s events ■ 2. Assist clients in identifying dysfunctional self-statements, beliefs, and patterns of thoughts that underlie their problem ■ 3. Assist clients in identifying situations that engender dysfunctional cognitions ■ 4. Assist clients in replacing dysfunctional cognitions with functional selfstatements ■ 5. Assist clients in identifying rewards and incentives for successful coping efforts ○ Strengths, limitations, and cautions of the approach Solution-focused brief treatment model ○ Post-modern, constructivist approach with unique focus on resolving client’s concerns ○ People were constrained by social construction of their problems ○ Goal of approach is to release client’s unconscious resources, thereby shifting from problem oriented perspective to one that is more solution based ○ Tenets of solution-focused brief treatment model ■ Customers - individuals who willingly make a commitment to change ■ Complainants - those who identify a concern but do not see themselves

as part of the problem or solution Visitor - person willing to be minimally or peripherally involved but isn’t invested in change effort ○ Theoretical framework ■ Borrows from social constructivists’ perspective that people use language to create their reality ○ Empirical evidence and uses of solution-focused strategies ■ Substantial evidence of effectiveness of approach in practice settings ○ Utilization with minors ■ Increasing evidence on effectiveness of solution-focused strategies with minors; public school settings show successful solution-focused therapy ○ Application of solution-focused approach with diverse groups ■ Critiques point to lack of attention to diversity of clients ○ Solution-focused procedures and techniques ■ Stages of solution building ● Description of the problem ● Developing well-formed goals ● Exploring exceptions ● End of session feedback ● Evaluating progress ■ Types of solution-focused questions ● Scaling questions - using scale of 1 to 10, solicit client’s level of willingness and confidence in moving toward developing solution ○ Used to observe progress ● Coping questions - highlight/reinforce client’s resources/strengths ● Exception questions - core of intervention; diminish problem focus, assist client to describe life when current difficulty did not exist ● Miracle questions - draw client’s attention to what would be different once a desired outcome is achieved ■ Techniques integrated into process of asking questions ● Compliments - provide feedback about client’s efforts and reinforce strengths and successes ● Bridging - feedback that clarifies goals, exceptions, or strengths ● Amplification - questions encourage clients to elaborate on “what’s different?” question ○ Strengths and limitations of the approach ■ Evidence shows efficacy with diverse populations and with variety of problems presented by clients ■ Question whether approach is collaborative ■ Discrepancies between clients’ experiences and observations made by therapists related to outcomes Case management ○ Entails work that interfaces between client and environment ■ Moved to forefront of direct SW practice to recognize that people with ■

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unmet needs are often unable to negotiate complex service systems Targeted case management - amendment to Budget Reduction Act of 2005, added as provision of Medicaid case management services ■ Certain beneficiary groups are considered to be primary recipients of targeted case management services Tenets of case management ■ Case management is not in and of itself a change-oriented intervention strategy, but it does involve elements similar to other approaches ■ Also referred to as case planning, care coordination, or patient-centered care; viable and often vital to persons in need of comprehensive services Standards of case management practice ■ Core elements of standards for practice based on set of beliefs and professional values considered to be essential to case management ● Utilizing comprehensive assessment to determine biopsychosocial functioning/care needs of clients, strengths, resources ● Client-centric, shared decision-making collaborative relationship between client and case manager ● Planning and implementing services that address and are responsive to unique needs of client/family ● Adhering to professional values/principles: self determination, privacy, confidentiality, informed consent, empowerment ● Primacy of obligation to client, which may involve advocacy, mediation, negotiation to ensure access to services ● Monitoring progress and evaluation of achievement of targeted outcomes ● Utilizing best evidence available to inform case management practice with specific populations, conditions, needs Empirical evidence of case management ■ Evidence of effectiveness cannot be generalized ■ Some studies support method’s efficacy with clients and families and specific conditions or problems Case management functions ■ Access and outreach ■ Intake and screening ■ Multidimensional assessment ■ Goal setting ■ Planning interventions and linking to resources ■ Monitoring progress and adequacy of services ■ Reassessment at fixed intervals ■ Outcome evaluation/termination Case managers ■ Fundamental to tasks; human interaction between clients and systems Strengths and limitations ■ Demonstrated effectiveness in addressing range of needs and problems

with specific populations Intended to meet multiple needs of client in coordinated, comprehensive manner Trauma-informed care: an overview of concepts, principles, and resources ○ Defining trauma ■ Single event, multiple events, or set of circumstances that is experienced by an individual as physically/emotionally harmful/threatening ● Has lasting adverse effects on individual’s social, emotional, and spiritual well-being ■ Three main types of trauma ● Type I - individual retains complete memory of experience ● Type II - repetitive, prolonged exposure to traumatic event, resulting in intense psychological/physical reactions ● Type III - multiple pervasive violent events (often in childhood); often cause severe, persistent psychological effects requiring different treatment strategies ○ The effects of trauma ■ Biological, psychological, social, spiritual ■ Impact associated with changes in brain neurobiology; social, emotional, cognitive impairment; health risk behaviors as coping mechanisms ○ Prevalence of trauma: what is known ■ High incidence/prevalence of trauma in general population ■ In children, led to involvement in juvenile justice system and residential treatment facilities ○ Trauma-informed care ■ Person-centered, strength-based service delivery approach in recognition of prevalence of trauma; clients across settings/human services systems ■ Trauma-informed approach - delivery of services and includes an understanding and awareness of impact/consequences of exposure ■ Trauma-specific interventions support/recognize ● Survivors’ need to be respected, informed, connected, hopeful regarding own recovery ● Interrelation between trauma and symptoms such as substance abuse, eating disorders, depression, anxiety ● Need to work in collaborative way with survivors, family, friends of survivor, other human services agencies to empower survivors ○ Six key principles of trauma-informed approach and trauma-informed care ■ Safety ■ Trustworthiness and transparency ■ Peer support and mutual help ■ Collaboration and mutuality ■ Empowerment, voice, and choice ■ Cultural, historical, and gender issues ○ The need for a trauma-informed service approach ■

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Evidence of the approach ■ Approach can ● Validate a part of people and a history that often has been dismissed or denied ● Create a safe place where people come for help, restoration, and motivation to continue ● Increase effectiveness of services designed to empower clients in transition periods ● Provide opportunity to plant seeds of hope, demonstrate that someone in this world cares about them, show clients they matter Implications for social work practice ■ Leads profession toward practice that is consistent with trauma-informed care despite work setting not being trauma informed...