WEEK 6 READING (CH 6 IN TEXTBOOK) (ASSESSING RISKS: Risk assessment - The…
WEEK 6 READING (CH 6 IN TEXTBOOK)
An ongoing process, in which we evaluate problems and strengths (those of both the client and their environment), for the purpose of deciding on action or intervention.
Purpose - to inform and shape the work that will follow.
Assessments often commence before the first contact between worker and client, and should continue right through to the end, when the results of the work are being evaluated.
A comprehensive, good-quality assessment relies on detailed knowledge about mental health, human development, family welfare and a range of other fields.
There are implications for WHAT we assess and also HOW we go about it.
Our approach to assessment is reflective of two major themes:
The focus of mental health social work on the social context and social consequences of mental illness
A focus on relationships in the lives of clients, and on relationships as a central element of the work.
WHAT WE ASSESS:
(Focuses on social factors, problems and strengths)
Focus of attention = the 'person-in-situation'
While in psychiatry the focus is individualised, in social work it also focuses on broader factors such as families, groups and communities in which the individual lives.
Uses the Biopsychosocial model, which provides a framework for assessing at all levels - biological, behavioural, individual, group, community. This model is also based on the idea that each of these levels affect the others.
As social workers, we focus on the relationships between people and their environments. This includes factors that cause stress and difficulty, as well as factors that sustain and support people. In this way, we are focusing on both problems and strengths.
CONSIDERATION OF STRENGTHS:
The capacity to cope with difficulties, to maintain functioning in the face of distress, to bounce back in the face of significant trauma, to use external challenges as stimulus for growth, and to use social supports as a source of resilience.
Strength include: personal qualities (attributes, talents and skills, interests and aspirations, interpersonal skills), strong intimate relationships, extended family good neighbours, the qualities of family members and other supportive people, and attributes of the available environment.
An assessment of strengths focuses on capabilities and aspirations in all areas of life, to discover the individual and communal resources that are available, and from which the client can draw.
HOW WE ASSESS:
(Focuses on relationships)
Assessment requires careful and detailed listening, in a two-way flow of information and an ongoing conversation.
Social workers aim to establish a 'Shared understanding' within the assessment process.
There are three broad models of the assessment process: Procedural, Questioning, Exchange.
The worker completes a form (with or without the client or some other significant person).
The form determines the agenda of assessment.
It's a simple, practical and relatively easy approach - however it may not necessarily go far towards meeting the actual or expressed wishes and needs of the client.
It tends to be formulaic (not original, individualised) and uncritical
The worker follows a format of questions, listening to and processing the answers.
The worker behaves as if they hold the expertise, and the interaction follows and reflects the worker's agenda.
This model is often used in situations in which eligibility for service needs to be established, or situations in which risk is a big issue.
The worker has assumed expertise in the process of problem-solving with others.
The real skill here lies in involving the client actively, which deliberately structures assessment processes to achieve as much involvement as possible.
It's more controversial and harder to use, especially when there may be pressure to establish certain facts.
This model typically includes more people and takes longer.
This model gives implicit value to the contribution of the client, so it tends to lead the worker to give credit to the clients 'expertise by experience'.
The assessment process can be the basis of an ongoing relationship:
Social workers must be willing to invest something of themselves in the relationship, in a thoughtful and considerate manner.
The appropriate attitude is one of respectful curiosity, not making assumptions or jumping to conclusions.
The worker needs to be clear and sensitive about the rights and responsibilities, and confidentiality (especially when it come's to the client's conflicts and power differences).
THE STAGES OF ASSESSMENT:
Assessment is a systematic, ongoing process (usually beginning before the worker meets the client).
Sometimes there is info available as part of the referral, or a file to read, or conversation from a professional or family member.
It's best and most responsible to be open to hearing as much info as possible, regardless of the source.
Assessment process stages:
1. Preparation -
determining who to see, what date will be relevant, what the purpose is, what the limits of the task are.
2. Gathering data (information) -
making sure we have an open mind
3. Weighing up the data -
especially determining whether we have enough info to decide what if any situations warrant and require our attention.
4. Analysing the data -
interpreting it to form an understanding of the situation that will help develop ideas for intervention.
5. Making use of the analysis -
in doing so, firming ip the understanding.
We will potentially seek information from:
The individual, family members and significant others
Professionals within the mental health service
Other service providers
Other members of the community with an interest (eg employers)
Wherever possible, the assessment should be conducted in natural community settings, such as a home visit.
PSYCHIATRIC DIAGNOSIS AND ITS PLACE IN ASSESSMENT:
Psychiatric diagnosis -
the application of a medical label to a psychological abnormality, using an accepted system of psychiatric classification (such as the DSM).
these classification systems seek to describe and define all those diseases, disorders and syndromes that fall within the ambit of the medical specialty of psychiatry, or 'the big five'.
1. Organic mental disorders
2. Syndromes of schizophrenia and related disorders, mood disorders and acute transient psychoses
3. Developmental disorders
4. non-psychotic (neurotic) disorders
5. Personality disorders
LIMITATIONS OF THE USEFULNESS OF PSYCHIATRIC DIAGNOSES:
Most psychiatric diagnoses do not have 'construct validity'
Social and psychological perspectives are often at least as important as the diagnosis.
The diagnosis itself something has significant negative effects (it tends to cement a particular view of the mental health problem, that privileges certain voices, and because problems of stigma and social exclusion are associated with mental health).
THE IDENTIFICATION OF COMMON MENTAL HEALTH PROBLEMS:
Those in the front-line (all social workers) need to be well connected to organised systems of mental healthcare for consultation and referral, in order to improve recognition and outcomes.
Social workers need to be aware of the basic 'building blocks' of psychiatric assessment. The main areas in which psychiatric disturbance my be manifest are: cognition, thinking, perception, mood and behaviour.
Conscious state, memory, concentration and attention, ability to calculate, executive functions.
Key disorders are delirium and dementia
Thought stream (logical/illogical, paranoia, suicidal thoughts).
Key disorder is Psychosis
Disturbance of any of the five senses (mostly hearing and vision), particularly hallucinations.
Key disorder is Psychosis
Key disorders are depression, bipolar disorder and anxiety disorder.
Eating, sleeping, social interaction, risk behaviour (suicidal and homicidal behaviour).
Key disorders are personality disorders, eating disorders, alcohol and drug problems.
MENTAL HEALTH ISSUES IN INFANTS/CHILDREN:
There is serious emotional distress in infancy, which is a crucial time to reduce later developmental difficulties.
Common disorders in childhood: Anxiety, depression, conduct disorder (CD), attention deficit hyperactivity disorder (ADHD).
Emotional disorders (such as anxiety and depression) can seriously impair learning and development.
Behavioural problems may disrupt social development and can lead to long-term mental health problems.
RISK FACTORS FOR DEPRESSION IN OLDER ADULTS:
Increase in physical health problems
Side effects of medications
Losses - relationships, independence, work and income, self-worth, mobility, flexibility.
Significant changes to living arrangements
-Admission to hospital
Particular anniversaries and the memories they evoke
THE MENTAL STATE EXAMINATION (MSE):
Provides a specific structured format for making an assessment of cognition, thinking, perception, mood and behaviour.
It's an inquiry into the symptoms and signs at the time of the interview, combined with a structured record of relevant observations.
MSE's are commonly undertaken by psychiatrists as part of the diagnostic process, however social workers need to be familiar with the content and application of this tool.
It is not a checklist
(Example of this tool being used is in textbook on page 157-159).
ASSESSING NEEDS FOR SERVICES:
Different clients will have different, diverse wishes and needs.
Any assessment of needs for service should take into account the
One of the main purposes of assessment surrounds decision-making about the allocation of resources.
(According to the DHS)
Emotional and mental wellbeing
Dealing with stress
Personal response to illness
Personal safety and the safety of others
Friendships and social relationships
Work, leisure and education
Daily living skills
Family's response to relative's illness
Rights and advocacy
Risk assessment -
The process of assessing the likelihood of a harmful event occurring and of estimating the likely impact on the patient, carers, staff and others should that event occur.
A good risk assessment requires consideration of both risk and protective factors.
Risk changes constantly and thus needs to be assessed continuously over time.
We tend to assume that our role is to 'manage' risk, by seeking to minimise or even eliminate it - which is often a difficult or impossible task,
Sometimes, it can be a positive thing for a client to take a risk (risks are not always something that should be avoided).
The aim of a risk assessment is NOT to categorise a person.
Danger to self through self-harm or suicide
Danger to self through self-neglect
Dangers arising from the lack of treatment, poor treatment or poor compliance with treatment.
Danger arising from offensive or provocative behaviour
Danger of exploitation (emotional, sexual, financial) by others
Dangers to others through assault (verbal, physical, sexual), exploitation, or abuse or neglect of children or dependent adults.
POSITIVE RISK ASSESSMENT:
Focuses on the benefits, advantages and opportunities of a particular course of action, as well as addressing the areas of risk, concern and potential harm.
The whole point of a risk assessment is to determine a plan in which you:
1. Identify the risk factors so they can be managed
2. Identify the protective factors so that they can be built on.
ASSESSING RISKS ARISING FROM ALCOHOL AND DRUG USE:
Alcohol and drug use tends to lead to poorer outcomes in mental health (it is associated with poor clinical and social outcomes, frequently poor general health and high levels of unmet need.
It is more common for people with a 'dual diagnosis' to experience a range of other problems (social, legal and criminal justice issues, housing welfare and other lifestyle issues).
There's a higher risk of suicide and violence.
It can be helpful to have a conversation about the client's pattern of substance use, and identify factors that maintain substance use, interfere with sobriety or represent a risk of relapse.
PRINCIPLES FOR ALCOHOL AND DRUG ASSESSMENT:
Convey acceptance and be non-judgemental
Assume a higher level of use in your discussions with the client
Ask about legal substances first
Ask about past use before asking about current use
Get specific information on amounts used and patterns of use
Collect information from a variety of sources.
Have some awareness of diagnostic criteria for substance dependence and abuse
Note, name and feedback concerns about substance-related risk factors.
ASSESSING THE RISK OF VIOLENCE AND HARM TO OTHERS:
While most people with a mental health problem don't engage in violence, the likelihood of committing violence is still greater than those who don't have a mental disorder.
Risk factors you can readily observe include hostility and suspiciousness, expressions of anger, irritability and agitation, and specific psychiatric symptoms (such as hallucinations, delusions or severe thought disorder)
FACTORS TO CONSIDER IN ASSESSING VIOLENCE AND HARM TO OTHERS:
Is there history?
Is the person currently showing signs of aggression or threatening behaviour
Does the content indicate risk of harm (to self or others)
Do they have a persecutory content
Is the content focused on particular people?
Do they create a sense of fear or persecution?
Is the person experiencing command hallucinations to harm (to self or others)?
Has the person expressed the idea of killing or harming others?
Is there an identifiable potential victim?
Neglect of dependants:
Does the person have a reduced/fluctuating capacity to care for children or other dependants such as elderly family members?
ASSESSING RISK ASSOCIATED WITH FAMILY VIOLENCE:
Some people (especially men) are violence towards family members.
People who experience family violence may be reluctant to reveal it (just as social workers are reluctant to ask).
Judging how and when to ask these questions requires social workers to be sensitive to family dynamics.
It's important to ensure that a violent situation is not made more dangerous for the victim (because of our actions).
Social workers need to explore:
The ways in which the person has been able to cope with the situation / How they've been able to survive.
What needs to happen to make them safe.
INITIAL QUESTIONS FOR PEOPLE WHO MAY BE VICTIMS:
How are things at home?
How and you are your partner relating?
Is there anything else that might be affecting your health / mental health?
More specific questions linked to observations:
You seem more anxious and nervous today. Is everything all right at home?
When I see injuries like this I wonder if someone could have hurt you?
Is there anything else that we haven't talked about that might be contributing to this condition?
More direct questions:
Are there ever times that you're frightened of your husband?
Are you concerned about your safety or the safety of your children?
Does the way your partner treats you make you feel unhappy or depressed?
Is it possible that there's a link between your illness/presenting features and the way your partner treats you? What do you think?
ASSESSING RISKS OF SUICIDE AND SELF-HARM:
All social workers, no matter what setting, need to be confident in making this kind of assessment and to respond effectively.
Many of us experience signs at some point in our lives, especially when we may be upset, stressed or tired.
Where a risk has been identified, it's critical to make an assessment of the seriousness of the risk, reflecting factors like whether the person has a plan and means to carry it out, the risk of impulsiveness and history of past attempts.
An assessment should take into account contextual factors as well as risk and protective factors.
Hopelessness, despair, agitation, shame, anger, guilt and psychosis escalate the risk.
Situational stressors can include financial distress, social disruption, onset of depressive illness, awareness of other suicide or self-harm.
Ask strength based questions.
The quality of the relationship between worker and client is an important factor in determining the quality of the risk assessment as well as the confidence the worker can have in it. So basically, there are two assessments that need to be done at the same time:
The degree of risk
The degree of confidence in the assessment
A judgement also needs to be made about how changeable the situation might be, and when a reassessment might need to be made, as well as is there any associated risk to others (neglect or harm to children).
There is a potential responsibility to act - hospitalisation or other place of safety.
Establish a careful plan, involving friends and family:
Marshalling supports to maintain safety
Ensuring that the person has good psychiatric treatment
Reducing psychosocial stressors and building protective factors
Planning in advance for contingencies
WARNING SIGNS FOR SUICIDE PREVENTION:
Threatening to hurt or take their own life
Looking for ways to take their own life or talking about their plan to do so
Talking or writing about death, dying or taking their life
Expressing feelings of hopelessness
Expressions of rage, anger or seeking revenge
Engaging in reckless or risky behaviours, seemingly without thinking
Expressed feelings of being trapped, like there's no way out
Increased use of alcohol or other drugs
Withdrawing from friends, family or the community
Anxiety or agitation
Abnormal sleep patterns
Dramatic mood changes
Giving away possessions or saying goodbye to people
Saying they have no reason to live / no sense of purpose
Families have often reported that the experience of being assessment has contributed to their sense of self-blame and fault, for the mental health problem of a family member (which is to be avoided for ethical and therapeutic reasons).
There must be a relationship with family members
The focus of the family assessment is to understand the point of view of each family member and how the family is dealing with the issues it confronts, and on looking at issues that will be relevant to the work that will follow.
Issues to look at can include: How the family communicates together, how they solve problems, the resources at their disposal to meet their needs in the context of a family member's mental illness.
The first thing to do is listen to their knowledge, experience and perspective on the situation.
INITIAL INFO FOR FAMILY ASSESSMENT:
Basic info: details about physical and mental health problems, significant stressors, whether they know who to contact in the service.
They way the person understands the client's mental health problem and its treatment, including what factors lead to improvement and things that make it worse.
They way the mental health problem affects the person and their coping strategies
Each person's daily life pattern, and sources of sustenance and satisfaction.
Each person's personal goals and their goals for the family as a whole.
ASPECTS TO CONSIDER WHEN ASSESSING INDIGENOUS MENTAL HEALTH:
Identify your own attitudes, values and beliefs
Respect community protocol (whether there are any ceremonies that may clash with your visit)
Find out who is the right person to speak with in the community
Ask whether it's appropriate for you to see this client
Consider engaging a cultural consultant
Reflect on the person's behaviour within the cultural context
Consider whether assessment tools are appropriate
Ask what factors you need to consider when interpreting the data
Consider traditional and non-traditional healing practices when deciding on appropriate intervention (practices of elders and community healers)
All written assessments should include succinct statements of the following, in a disciplined and specific manner:
1. A statement of how the situation is understood
2. A statement of needs
3. A statement of the desired outcomes of care and treatment.
A good plan is to write as if the client will read what you have put down (they may actually read it if its appropriate).
Data collection methods such as eco-maps, social network maps and life charts inform the assessment (adds weight to it), it does not replace it.
Because each entry in the file contribute to the written assessment, the best way to go about it is to use a template such as SOAP.
Regular reviews need to be undertaken, to incorporate new information and perspectives and also to retain the focus on shared understanding of problems and strengths.
SOAP RECORDING TEMPLATE:
ubjective - What the client tells you (what they say, how they say it, expressed feelings and perceptions
bjective - What you observe
ssessment - Diagnoses, interpretation of the subjective and objective information
lan - Following from the assessment: interventions used/planned to achieve goals, treatment progress