Introduction to Social Work Practice: A Practical Workbook

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Herschel Knapp

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  • Front Matter
  • Back Matter
  • Subject Index
  • Part I: Defining the Professional Relationship

    Part II: Mutual Understanding

    Part III: The Process

  • Dedication

    For Mom and Dad

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    Preface

    Tell me, and I'll forget. Show me, and I may remember. Involve me, and I'll understand.

    —Anonymous

    Welcome to this workbook. The purpose of this text is to orient you to the field of social work practice. In a nutshell, one might think of the social work profession as an opportunity to help improve the quality of people's lives. One of the privileges of being a social worker is the diversity of opportunities that are available in the workforce. Depending on your talents, training, interests, and opportunities, you may find yourself working in a variety of capacities ranging from adoption to hospice care. While some members of the social work profession dedicate themselves to the administrative, planning, or policy development services, others will have more direct contact with clients. Regardless of your long-run goals, your proficiency with the skills detailed in this text will provide you with an essential foundation for advancing your social work career.

    This book presents an introduction to the practice principles and ethics of the social work profession, an essential set of communication skills that can be used to work effectively with clients and peers in a variety of settings, and an intuitive five-step problem-solving template to help focus your collaborative efforts with clients. The text is organized into three sections:

    Part I, Defining the Professional Relationship (Chapter 1), delineates key differences between your role as a social helper, informally providing supportive guidance to family, friends, and acquaintances, and your evolving role and responsibilities in your professional capacity as a social work practitioner.

    Part II, Mutual Understanding (Chapter 2), provides a variety of communication skills and principles used for working proficiently with clients and colleagues.

    Part III, The Process (Chapters 37), presents a five-step problem-solving model—Assessment, Goal, Objectives, Activation, and Termination (acronym: A GOAT)—as a vehicle for collaboratively advancing the client through the change process:

    Step IAssessmentWhere is the client now?
    Step IIGoalWhere does the client want to be?
    Step IIIObjectivesHow does the client get from here to there?
    Step IVActivationMoving from intention to implementation
    Step VTerminationContinuing the mission independently

    You have likely used something akin to this intuitive problem-solving model, perhaps without articulating each discrete step, in your efforts to achieve a variety of goals, as in this tangible example:

    Step IAssessmentI have a car, and I'm currently in Southville.
    Step IIGoalI want to get to Northland.
    Step IIIObjectivesI need a map, directions, fuel, food, and drink.
    Step IVActivationStarting tomorrow, I'll drive from 8:00 a.m. to 4:00 p.m.
    Step VTerminationWhen I arrive in Northland, I'll get my bearings [next Assessment], and then here's what I'll do… [next Goal] …

    The above example demonstrates how you can apply this model in a successive fashion wherein the accomplishment of one goal logically leads to the identification and pursuit of the next step in a progressive mission. Alternatively, the accomplishment of one goal may lead to the pursuit of an entirely different project.

    The five-step process demonstrated in Chapters 37 should be considered as a suggested framework for conceptualizing and executing the path through a case. As with many other stepwise models, it is recognized that real life does not necessarily happen in a linear order. For example, the first topic that a client may wish to discuss may be his or her goal (Step II in the model). Alternatively, a client who is allotted a limited number of sessions may feel driven to discuss concerns regarding termination (Step V) early in the process. Additionally, expect that throughout the natural course of working with clients, there may be a bit of justifiable jumping around from step to step. Consider a case in which the client is at the activation phase (Step IV), during which a critical figure in his or her life becomes no longer able to provide support, whether in the form of emotional encouragement, financial aid, accommodations, or other assistance. This may require revisiting other steps, which might involve reassessing the client's condition (Step I), reevaluating the goal (Step II), identifying alternate objectives (Step III), and so on. In short, consider thinking of the proposed model as a guide, not a straitjacket. Also, keep in mind that in most stepwise models, the advancement from one step to another may take the form of discrete, identifiable breaks; other times, advancement through the steps can be more of a seamless progression. As you gain experience, consider adapting the model proposed in this text in a fashion that accommodates your own personality, approach to social work, theoretical orientation, setting, and each client's distinctive characteristics and needs.

    For sake of brevity and clarity, the examples and exercises contained in this workbook focus primarily on interventions with individuals; however, this problem-solving model is relatively portable. It is compatible with a variety of theoretical orientations and settings (e.g., couple, family, group, community).

    In simplistic terms, you might think of the social work process as an intertwined two-part mission: Part 1 involves gaining an understanding of the client and the client's system/living environment. Part 2 entails using your comprehension of the client's realm to collaboratively work toward helping him or her evolve into the next higher version of him- or herself. This is accomplished via setting and executing meaningful goals based on the client's talents, resources, and preferred life direction.

    Some acronyms are used to present systematic models throughout the text. It is not the author's intent to have you merely memorize and reproduce these models verbatim on demand—that kind of learning has little real-world value and is typically forgotten promptly after finals. Rather, the mnemonic devices and proposed models are presented as tools to organize concepts in order to help you build a cohesive image in your mind. Naturally, you will need to be flexible when applying these tools and techniques in order to accommodate the unique characteristics of each client, his or her situations, and your own style.

    Throughout the text, there are dialogue examples consisting of two streams of text: (1) Italicized text represents the script of the spoken words between the social worker and the client. (2) Roman (nonitalicized) text provides a running commentary detailing the social worker's thought process, progressive impressions, intentions, and rationale.

    Throughout this text, there are multiple references to the Code of Ethics of the National Association of Social Workers (NASW). It is recommended that you familiarize yourself with the most recent version, which can be found online at the NASW public Web site: http://www.socialworkers.org. It will be helpful to have access to the NASW Code of Ethics as you proceed through this text.

    Through your desire to help, your natural curiosity, and the application of social work theories, ethics, and principles, you will have the opportunity to come to know the unique world that is each client. Embrace the privilege to help advance the quality of life of those you serve.

    Overview of Exercises

    This text is presented as an interactive workbook, enabling you to apply and reinforce your understanding of the materials as you advance through the text. Exercises in the form of concept reviews, discussion points, and role-plays are presented at the conclusion of each chapter.

    Concept Reviews

    Concept reviews provide a means for consolidating key ideas presented in each chapter. In addition to the meaning that you derive from the text, your personal perspective, experiences in your field settings, and peer consultations will undoubtedly influence your unique interpretation and implementation of each concept in your actual social work practice settings. Hence, make an effort to use your own ideas and experiences when responding to concept review questions as shown in Figure A.

    Figure A Sample Concept Review
    Discussion Points

    Discussion points offer you and your colleagues the opportunity to exchange ideas and opinions on a diverse array of social work issues. The purpose of such discussion points is to provide a forum to help you integrate the discrete points raised in the text with your personal experience and perspective.

    The goal of these discussion points is not necessarily to identify the right answer and to arrive at a generally acceptable consensus, though in some cases this may occur. Rather, consider these discussion points as a means for exploring the diversity of clinical issues, alternatives, dilemmas, and ethics from multiple subjective vantage points. Such open discussions can provide you with alternate ways of conceptualizing a case or suggest additional frameworks within which to approach a problem. Write down the ideas that emerge. You may use “+” and “−” signs to flag ideas that you do and do not agree with, as shown in Figure B. Your instructor may have you complete these exercises as class discussions, small groups, pairs, or solo (without the + / − indicators).

    Figure B Sample Discussion Points
    Role-Plays

    The role-play exercises enable you to practice implementing the principles and skills presented in a safe, simulated, real-life setting. Each role-play specifies the client's characteristics and circumstances and suggested performance parameters for the client and the social worker. The role-plays are meant to approximate an actual encounter with a client. As such, try to avoid the temptation to script or rehearse the role-plays in advance, as this can stiffen or constrain the spontaneity and natural flow of the experience.

    Before or during the role-plays, feel free to enhance or modify the existing scenario, within reason. As you gain more experience, you may choose to invent additional role-play scenarios of your own. This can help bring a sense of realism to these practice situations.

    The clients in the role-plays have been assigned unisex names and gender-free circumstances. This means that either a female or a male can plausibly play the part of the client.

    The person playing the part of the client should adjust his or her performance to the approximate skill level of the person acting as the social worker. For example, if you are finding that a role-play is too easy for the social worker, consider incrementally stepping up the situation by adding some complicating factor(s). Conversely, if the social worker seems to be struggling with the role-play, consider reducing the complexity of the client's problem or adjusting the client's attitude accordingly.

    The person playing the social worker may use the skills suggested but need not necessarily constrain him- or herself to that brief list. As your skill base builds, you will likely become more comfortable in the role-play process. Consider saying, within reason, whatever seems necessary in order to effectively implement the role-plays.

    You may wish to specify supplemental client characteristics that are not stated in the text. Briefly negotiate this with your partner prior to embarking on the role-play. For instance, as you gain more experience and comfort in performing the role-plays, you may want to consider portraying the client as coming from a cultural or an ethnic background that is different from your own. To facilitate authenticity, you may wish to consider aptly renaming the client. This can offer the person playing the social worker the opportunity to implement the communication skills in a fashion that is conducive to the client's unique social attributes.

    During a role-play, you may find yourself stuck or having an unexpected adverse emotional reaction. Occasionally, engaging in or even observing a role-play can conjure up strong feelings, thoughts, or memories. If this happens, raise your hand and say, “Wait” or “Stop,” indicating that you need to suspend the role-play. Take some time to confer with your partner, classmates, or instructor to address your questions or feelings. Also, if you notice that your role-play partner or someone else present is having an adverse reaction to the role-play, consider halting the role-play to tend to his or her reaction. Remember: Real life takes precedence over role-plays. After the issues are settled, the participants should mutually decide if a role-play should be resumed from where you left off, restarted from the beginning, or abandoned.

    Role-Play Debriefing

    Role-plays should run about 5 to 10 minutes. Consider using a stopwatch or a countdown timer. To end a role-play, say something like, “OK, let's stop here” or “Cut.” This explicit statement marks the end of the role-play, at which time both participants are to halt their portrayal of the fictitious characters.

    After each role-play, participants should take some time to informally talk about their emotional experience as it pertains to their portrayals in the role-play. Next, the person who played the social worker should discuss the role-play from an evaluative standpoint:

    • What skills did you feel most comfortable with?
    • What skills do you feel you need to improve?
    • What were the most challenging parts of the role-play?
    • What do you wish you would have said or done differently?
    • What goal did you have in mind?
    • Did something surprise you?
    Providing Role-Play Feedback

    The purpose of the role-plays is to offer you the opportunity to take the skills from the printed page and “test-drive” them in a safe, near-to-real-life environment where nobody can get hurt. The ultimate goal of role-playing is to recognize points of proficiency and, most essentially, to identify opportunities for improvement.

    Constructive criticism can be challenging to assemble and tactfully deliver; however, politely withholding negative feedback essentially defeats the purpose of the role-play experience. Failing to point out areas that can be improved is a disservice to the individual, as well as to the multitude of clients that he or she will encounter who may benefit from more effective communication.

    After each participant has processed his or her initial feelings, the person who played the client should provide some feedback to the individual who portrayed the social worker. The person who played the social worker should take detailed notes as he or she is receiving the feedback.

    The person who played the client should start by offering some genuine positive feedback. Describe the skill(s) that the person demonstrated most proficiently. Next, it is time for some constructive criticism. While it is important to provide an honest appraisal of your peer's performance, it is equally essential not to overwhelm him or her. Focus on offering feedback on one or two skills that you feel need the most improvement.

    People are more receptive when feedback is phrased in a positive and specific fashion.

    In terms of speaking positively, instead of saying, “You had a very cold attitude,” consider saying something like, “I can see that you were trying to be efficient, but I think I would have felt more relaxed if you were a little more personable and less officious.”

    With respect to specificity, it is OK to begin with some general feedback (e.g., “You seemed to have a judgmental attitude with this client.”), but to the extent possible, provide specific examples supporting your general evaluation. Wherever possible, use actual quotes or paraphrase specific instances in the interview that support your claims (e.g., “When you said, ‘I can't believe that you'd even think of doing XYZ,’ it felt like you were judging me. From that point on, I really didn't want to tell you much more about anything.”). Consider taking some notes during these exercises. These notes can be useful in providing specific feedback after the role-play.

    Next, the person who portrayed the social worker may respond to the person who played the client.

    If observers are present, they may offer their impressions of the social worker's performance one at a time. Observers are welcome to briefly reiterate positive feedback that has already been given, but each observer should restrict negative feedback to one recommendation. Avoid repeating negative feedback that has already been mentioned.

    Finally, the person who is being reviewed should take some time to verbalize his or her peers’ positive remarks, along with the recommendations that were given and his or her related feelings. The ultimate goal of the role-play process is for the person playing the social worker to compose a customized “to-do” list (e.g., “It seems like I'm fairly solid with skills A and B—those come pretty naturally—but it looks like I need to work on applying X and Y. Those still felt a little bit awkward to me.”) and build a plan for improving those skills.

    After each role-play wherein you play the social worker, complete the corresponding self-evaluation worksheets. As objectively as possible, rate your proficiency with each skill used according to the numbered scale (1 = needs further work, 5 = excellent), and write a brief note as shown in Figure C. Notice that in Figure C, two additional blank rows are provided for you to list and evaluate your use of supplemental skills (e.g., Clarification) that were not specifically included in the role-play parameters. The purpose of this self-evaluation is to focus your skill development efforts by identifying proficiencies and specific areas to improve.

    Figure C Sample Role-Play Evaluation Form
    Role-Play Case Notes

    Document your brief encounter in case note style, as if you were making an actual entry in the client's chart as shown in Figure D. This will enable you to practice your documentation skills while considering the nature of the exchange that you had with the client.

    Figure D Sample Role-Play Case Notes

    Role-plays, though simulated situations, can be exhilarating. These exchanges can be emotionally and cognitively intense for participants and observers. After completing a role-play, debriefing, and documentation, consider taking a moment to clear your head. After a brief break, you and your partner may choose to exchange roles and rerun the exercise for additional practice. As your skills evolve, you may wish to consider revisiting some of the role-plays, taking note of improvements in your performance over time.

    As you embark on the role-play exercises, try not to be too hard on yourself or your peers. As with any skill that demands real-time implementation, this sort of communication can take some time to achieve proficiency. Even the most capable social workers occasionally misspeak or misunderstand. With practice, you will find yourself intuitively employing these skills, enabling you to focus less on the names and parameters of each skill and more on the client's issues. Enjoy the process.

  • Appendix A: Sample Mental Status Exam (MSE)

    As stated earlier in the text, there is no universal format for a mental status exam (MSE). The content may vary depending on such things as setting, agency practices, forms, client population, level of detail available, and the time allotted to carry out an MSE. The following are some of the topics commonly covered in an MSE:

    • Condition under which the MSE is conducted
    • Description of person/appearance
    • State of consciousness
    • Orientation
    • Motor behavior
    • Affect
    • Speech quality
    • Thought process
    • Thought content
    • Perceptions
    • Judgment
    • Memory
    • Intellectual functioning
    • Mental health diagnosis
    • Treatment recommendations

    The following is a sample of a fairly typical MSE. For clarity, each section begins as a new paragraph beginning with the section header. Alternatively, this could have been written in a more narrative fashion, without explicit section breaks.

    MSE for Adrian

    Condition under which the MSE is conducted—Adrian was interviewed in a private one-on-one office at Acme Mental Health Center during her first appointment on July 16 at 4:00 p.m. Adrian is a new client brought in by her parents who are concerned, describing her as “so depressed and dark.” Adrian confirms that there have been persistent (verbal) confrontations with her parents and academic problems, both of which have grown progressively worse over the past 6 months.

    Description of person/appearance—Adrian is a 16-year-old Caucasian female, approximately 5 ft, 10 in. (about 1.8 m), of appropriate weight, with fair skin; long, straight, light-brown hair; blue eyes; and no glasses. She presents as moderately attractive and well groomed, with good personal hygiene, age-appropriate clothing and use of cosmetics (skillfully applied facial makeup and elaborate multicolored nail polish), pierced ears (one pierce in each earlobe), and no observable tattoos or scars, and she is wearing seven rings (costume jewelry)—two on some fingers. She carries a simple, average-sized purse.

    State of consciousness—Adrian presents as alert and oriented x3. She is attentive and provides prompt and reasonable responses to most questions.

    Motor behavior—Adrian's stride is somewhat slow—once seated, she sat fairly still with her arms crossed most of the time.

    Affect—Adrian presents with a good range of emotion that is context appropriate. Initially, she presented as fairly blunted with limited facial expression and negative eye contact. She describes her overall mood as “terrible … just bad,” which is consistent with her discussion of circumstances at home and school. She exhibits some elevation in her affect when discussing her boyfriend and hopes for an enduring and loving future with him.

    Speech quality—Verbalizations are articulate and tend to be consistent with her depressive affect: slow, low in volume, occasionally to the level of a whisper. When her voice becomes inaudible, she belligerently repeats her words or phrases upon (courteous) request. Adrian tends to resist engaging in dialogue—her adaptation (in this setting) is to respond to questions in a relatively brief fashion. After warming up, her responses became somewhat more forthcoming and detailed.

    Thought processAdrian presents with cogent thinking. Her responses to questions, though occasionally briefly delayed, reflect attentiveness and logical/linear reasoning, appropriately addressing the questions as asked. She demonstrates the ability to reason concretely and abstractly in manners that are contextually appropriate.

    Thought content—Adrian's thoughts seem to focus on her perception that her parents are unnecessarily rigid in their thinking, rules, punishments, and overprotective style. Adrian explains that this interferes with her ability to speak and act freely/spontaneously and restricts her interaction with friends (e.g., curfews, no sleepovers, no out-of-town travel with friends). There is no evidence of thought disorders or dangerousness to self or others.

    Perceptions—Adrian does not exhibit signs of perceptual anomalies and denies any history of hallucinations or illusions but does report occasionally having exceptionally vivid dreams during nocturnal sleep about once a week over the last few months.

    Judgment—Adrian presents with appropriate judgment, guided by a good sense of conscience, reasonably anticipating the consequences of her actions.

    Memory—Memory appears to be intact: reliable and rapid recall of immediate, recent, and remote incidents.

    Intellectual functioning—Adrian's conversational engagement demonstrates her ability to think effectively both concretely and abstractly. Adrian comfortably and appropriately demonstrates a sophisticated vocabulary and analogical thinking. Prior academic report cards indicate above-average academic performance despite comments detailing recurring disruptive/distracting socializing with peers during class time. More recent report cards show a substantial decline in marks, classroom conduct, and verbal confrontations with teachers.

    Mental health diagnosis

    I: 296.22—Major Depressive Disorder, Single Episode, Moderate (provisional)

    V61.20—Parent-Child Relational Problem

    II: V71.09—No Diagnosis on Axis II

    III: Adrian reports no physical health problems or diagnoses and no history of major injuries or accidents.

    IV: Persistent confrontations over multiple issues with parents, escalating over past 5–6 months. Low to moderate sibling and peer support. Academic problems appear to be secondary to family and social stressors.

    V: GAF = 68 (current), 82 (highest in last year)

    Treatment recommendations—Recommend weekly individual sessions with Adrian along with weekly family sessions to assess general family history, structure, norms, functioning, and dynamics among parents and siblings. To provide referral to Dr. Ralston for mental health evaluation for possible short-term use of antidepressant medication. To coordinate treatment plan with Dr. Ralston and monitor progress. To reassess in 3 months.

    Appendix B: Diagnostic Terminology

    The following is a partial list of diagnostic terminology that you may encounter or use in case documentation.

    • Agitation—Small movements
    • Agnosia—Unable to recognize or identify objects
    • Alogia—Poverty of speech (brief, empty replies)
    • Anhedonia—Unable to experience any pleasure (prolonged)
    • Aphasia—Disorganized language
    • Apraxia—Inability to do motor tasks
    • Ataxia—Uncoordinated muscular movements
    • Avolition—Inability to initiate and persist in goal-directed activities
    • Bradycardia—Slow pulse
    • Catalepsy—See “Waxy flexibility”
    • Catatonic excitement—Unstimulated excessive motor activity
    • Catatonic negativism—Resistance to instruction or attempts to being physically moved
    • Catatonic posturing—Inappropriate or bizarre physical positioning
    • Catatonic rigidity—Rigid posture, resistance to being physically moved
    • Circumstantial speech—Includes excessive nonessential details in responses or storytelling
    • Delusion—False belief system
    • Dysarthria—Neurological speech impediment
    • Echolalia—Repeating the interviewer's word(s) verbatim
    • Echopraxia—Mirroring others’ physical actions
    • Hyperactivity—Larger movements
    • Hyperacusis—Very sensitive to sound
    • Hypnagogic phenomenon—Hallucination occurring just prior to falling asleep
    • Ideas of influence—Believing that others control one's thoughts
    • Ideas of reference—Believing that other things, people, or events are related to oneself
    • Labile—Quickly cycling affect
    • Logorrhea—Too much speech
    • Macropsia—Perceiving objects as larger than they actually are
    • Micropsia—Perceiving objects as smaller than they actually are
    • Myocardial infarction (MI)—Heart attack
    • Nystagmus—Involuntary rapid eye oscillations
    • Orientation—(x3) person, place, time
    • Postpartum—After childbirth
    • Poverty of speech—Too little speech
    • Preservation—Needless repetition of same idea
    • Pressured speech—Speaks fast or in a high volume; may be difficult or impossible to interrupt
    • Psychomotor retardation—Movements too idle
    • Stereotypical movement—Repetitive non-goal-directed movements
    • Tachycardia—Elevated pulse
    • Thought broadcasting—Believing that others are hearing or receiving one's thoughts
    • Thought insertion—Believing that others put thoughts into one's head
    • Waxy flexibility—Able to pose client into unusual, sustained positions (with catatonic schizophrenics)

    Appendix C: Documentation, Symbols, and Abbreviations

    Some clinical settings accept selected symbols and abbreviations in case documentation; others do not. Be sure to find out what style of documentation is customary at each facility. The following is a list of some of the most commonly used symbols and abbreviations.

    Notations often used in social work settings:

    • ↓—Decrease
    • ↑—Increase
    • ψDx—Mental health diagnosis (DSM)
    • A/Ox3—Alert and fully oriented (to person, place, and time)
    • &cmacr;—With
    • Cl—Client
    • D/C—Discharge or discontinue
    • Dx—Diagnosis
    • F/T—Follow-through
    • Hx—History
    • &pmacr;—After
    • Px—Problem
    • R/T—Related to
    • S/O—Significant other
    • Sw—Social worker
    • Th—Therapist
    • Tx—Treatment

    Supplemental notations often used in medical social work settings:

    • BID—Twice a day
    • NPO—Nothing by mouth
    • PRN—As needed
    • Pt—Patient
    • Q4H—Every 4 hours (can use any number)
    • QD—Once daily
    • QID—Four times a day
    • QOD—Every other day
    • Rx—Prescription
    • Sfx—Side effects
    • TID—Three times a day

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    About the Author

    Herschel Knapp, PhD, MSSW, is a psychotherapist and health science researcher in Los Angeles, California. His experience includes helpline work, acute care in hospitals (ER, ICU, CCU, oncology), and longer-term psychotherapy in both in- and outpatient settings with a diverse client population. He has served as a behavioral science representative advocating for quality of life on the Patient Care Committee, Palliative Care Committee, Ethics Committee, and Cancer Committee. He has taught at the university level, provided intern supervision, and presented numerous clinical trainings in hospitals, schools, and the community. He is currently involved in biobehavioral research directed at improving healthcare services to cancer patients and enhancing access to HIV testing. He is a member of the National Association of Social Workers and the American Psychological Association. His contributions to the field have earned him membership in Phi Kappa Phi Academic Honor Society, Phi Alpha National Honor Society for Social Work, and Who's Who Among Students in American Universities and Colleges. He is the author of the textbook Therapeutic Communication: Developing Professional Skills (2007).


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