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Fundamentals of Case Management Practice Skills for the Human Services

N a N c y S u m m e r S Harrisburg Area Community College

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Fundamentals of Case Management Practice: Skills for the Human Services, Fifth edition Nancy Summers

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To my parents, whose humor and wisdom about people and relationships formed the foundation for my work with others

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iv Contents

Preface xiii

Section 1 Foundations for Best Practice in Case Management

Chapter 1 Case Management: Definition and Responsibilities 1

Introduction 1 A History of Case Management 2 Language in Social Services 2 Why We Use Case Management 3 Case Management as a Process 4 Advocacy 13 Service Coordination 13 Levels of Case Management 16 Separating Case Management from Therapy 19 Case Management in Provider Agencies 19 Managed Care and Case Management 21 Caseloads 25 Generic Case Management 26 Summary 26 Exercises I: Case Management 27 Exercises II: Decide on the Best Course of Action 30

Chapter 2 Ethics and Other Professional Responsibilities for Human Service Workers 33

Introduction 33 The Broader Ethical Concept 34 Dual Relationships 35 Boundaries 40 Value Conflicts 40 The Rights of Individuals Receiving Services 44 Confidentiality 47 Privacy 51 Health Insurance Portability and Accountability Act 52 Social Networking 55 Privileged Communication 56 When You Can Give Information 56 Diagnostic Labeling 59

Contents

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Contents v

Involuntary Commitment 60 Ethical Responsibilities 61 Protecting a Person’s Self-Esteem 62 Stealing from Clients 64 Competence 65 Responsibility to Your Colleagues and the Profession 65 Professional Responsibility 67 Summary 68 Exercises I: Ethics 69 Exercises II: Ethically, What Went Wrong? 71 Exercises III: Decide on the Best Course of Action 76 Exercises IV: What is Wrong Here? 76

Chapter 3 Applying the Ecological Model: A Theoretical Foundation for Human Services 77

Introduction 77 The Three Levels of the Ecological Model 79 The Micro Level: Looking at What the Person Brings 80 Looking at What the Context Brings 80 Why Context Is Important 81 Seeking a Balanced View of the Client 82 Developmental Transitions 86 Developing the Interventions 87 Working with the Generalist Approach 88 Macro Level Interventions Are Advocacy 88 Summary 90 Exercises I: Looking at Florence’s Problem on Three Levels 90 Exercises II: Designing Three Levels of Intervention 91

Section 2 Useful Clarifications and Attitudes

Chapter 4 Cultural Competence 95

Introduction 95 Culture and Communication 95 Your Ethical Responsibility 96 Where Are the Differences? 96 Strangers 98 Anxiety and Uncertainty 99 Thoughtless versus Thoughtful Communication 100 Dimensions of Culture 104 Obstacles to Understanding 109 Competence 111 Summary 112 Exercises I: Testing Your Cultural Competence 113

Chapter 5 Attitudes and Boundaries 117

Introduction 117 Understanding Attitudes 117 Basic Helping Attitudes 118

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vi Contents

Reality Check 123 How Clients Are Discouraged 124 A Further Understanding of Boundaries 127 Seeing Yourself and the Client as Completely Separate Individuals 127 Erecting Detrimental Boundaries 129 Transference and Countertransference 129 Summary 130 Exercises I: Demonstrating Warmth, Genuineness, and Empathy 131 Exercises II: Recognizing the Difference—Encouragement

or Discouragement 136 Exercises III: Blurred Boundaries 136

Chapter 6 Clarifying Who Owns the Problem 139

Introduction 139 Boundaries and Power 140 If the Client Owns the Problem 141 If You Own the Problem 143 If You Both Own the Problem 144 Summary 145 Exercises I: Who Owns the Problem? 145 Exercises II: Making the Strategic Decision 147

Section 3 Effective Communication

Chapter 7 Identifying Good Responses and Poor Responses 149

Introduction 149 Communication Is a Process 150 Twelve Roadblocks to Communication 151 Useful Responses 156 Summary 164 Exercises: Identifying Roadblocks 165

Chapter 8 Listening and Responding 169

Introduction 169 Defining Reflective Listening 170 Responding to Feelings 170 Responding to Content 174 Positive Reasons for Reflective Listening 176 Points to Remember 177 Summary 178 Exercises I: How Many Feelings Can You Name? 179 Exercises II: Finding the Right Feeling 179 Exercises III: Reflective Listening 180

Chapter 9 Asking Questions 187

Introduction 187 When Questions Are Important 187 Closed Questions 188 Open Questions 189

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Contents vii

Questions That Make the Other Person Feel Uncomfortable 190

A Formula for Asking Open Questions 192 Summary 195 Exercises I: What Is Wrong with These Questions? 195 Exercises II: Which Question Is Better? 197 Exercises III: Opening Closed Questions 198 Exercises IV: Try Asking Questions 200

Chapter 10 Bringing Up Difficult Issues 203

Introduction 203 Confrontation 203 Exchanging Views 204 When to Initiate an Exchange of Views 204 Using I-Messages to Initiate an Exchange of Views 207 Asking Permission to Share Ideas 213 Advocacy: Confronting Collaterals 214 On Not Becoming Overbearing 215 Follow-up 217 Summary 217 Exercises I: What Is Wrong Here? 217 Exercise II: Constructing a Better Response 219 Exercises III: Expressing Your Concern 219 Exercises IV: Expressing a Stronger Message 222

Chapter 11 Addressing and Disarming Anger 225

Introduction 225 Common Reasons for Anger 225 Why Disarming Anger Is Important 226 Avoiding the Number-One Mistake 227 Erroneous Expectations for Perfect Communication:

Another Reality Check 228 The Four-Step Process 229 What You Do Not Want to Do 231 Look for Useful Information 233 Safety in the Workplace 233 The Importance of Staff Behavior 234 Summary 235 Exercises I: Initial Responses to Anger 235 Exercises II: Practicing Disarming 236

Chapter 12 Collaborating with People for Change 239

Introduction 239 What Is Change? 239 Stages of Change 240 Understanding Ambivalence and Resistance 244 Encouragement 247 Recovery Tools 250 Communication Skills That Facilitate Change 252

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viii Contents

Trapping the Client 258 From Adversarial to Collaborative 258 Summary 262 Exercises: Helping People Change 263

Chapter 13 Case Management Principles: Optional Review 265

Introduction 265 Combining Skills and Attitudes 265 Practice 267 Exercise I 267 Exercise II 268 Exercise III 271 Exercise IV 273 Exercise V 274

Section 4 Meeting Clients and Assessing Their Strengths and Needs

Chapter 14 Documenting Initial Inquiries 277

Introduction 277 Walk-ins 278 Guidelines for Filling Out Forms 278 Steps for Filling Out the New Referral

or Inquiry Form 278 Evaluating the Client’s Motivation

and Mood 282 Steps for Preparing the Verification of Appointment Form 282 Summary 284 Exercises I: Intake of a Middle-Aged Adult 284 Exercises II: Intake of a Child 284 Exercises III: Intake of an Infirm, Older Person 285

Chapter 15 The First Interview 287

Introduction 287 Your Role 288 The Client’s Understanding 288 Preparing for the First Interview 288 Your Office 290 Meeting the Client 290 Summary 295

Chapter 16 Social Histories and Assessment Forms 297

Introduction 297 What Is a Social History? 298 Layout of the Social History 298 How to Ask What You Need to Know 299 Who Took the Social History 306 Social Histories in Other Settings 310 Writing Brief Social Histories 311

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Contents ix

Using an Assessment Form 314 Taking Social Histories on a Computer 316 Taking Social Histories in the Home 316 The Next Step 317 Summary 317 Exercises I: Practice with Social Histories 318 Exercises II: Assessment of a Middle-Aged Adult 318 Exercises III: Assessment of a Child 319 Exercises IV: Assessment of an Infirm, Older Person 320 Exercises V: Creating a File 320

Chapter 17 Using the DSM 321

Introduction 321 Is DSM Only a Mental Health Tool? 322 Cautions 322 Who Makes the Diagnosis? 323 Background Information 323 The DSM-IV-TR 327 DSM 5, the Current Diagnostic Manual 328 Making the Code Using DSM 5 330 Multiple Diagnoses 331 Other Conditions That May Be a Focus

of Clinical Attention 332 When the Diagnosis Does Not Quite Fit 332 When There Is No Number 333 Summary 333 Exercises: Using the DSM 5 334

Chapter 18 The Mental Status Examination 337

Introduction 337 Observing the Client 338 Mental Status Examination Outline 339 Summary 356 Exercises: Using the MSE Vocabulary 356

Chapter 19 Receiving and Releasing Information 359

Introduction 359 Sending for Information 359 If You Release Information 359 Directions for Using Release Forms 360 Examples of the Release Forms 362 When the Client Wants You to Release Information 363 When the Material Is Received 363 Other Issues Related to Releasing Information 365 Summary 365 Exercises I: Send for Information Related to a

Middle-Aged Adult 366 Exercises II: Send for Information Related to a Child 366 Exercises III: Send for Information Related to a Frail,

Older Person 366 Exercises IV: Maintaining Your Charts 366

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x Contents

Section 5 Developing a Plan with the Client

Chapter 20 Developing a Service Plan at the Case Management Unit 367

Introduction 367 Involving the Client and the Family 368 Using the Assessment 369 Creating the Treatment or Service Plan 372 How to Identify the Client’s Strengths 373 Individualized Planning 374 Understanding Barriers 375 Sample Goal Plan 375 Summary 376 Exercises: Broad General Goal Planning 377 Exercise I: Planning for a Middle-Aged Adult 377 Exercise II: Planning for a Child 377 Exercise III: Planning for an Infirm, Older Person 377 Exercise IV: Maintaining Your Charts 377 Exercise V: Checking Services 378

Chapter 21 Preparing for a Service Planning Conference or Disposition Planning Meeting 379

Introduction 379 What You Will Need to Bring to the Meeting 380 Goals for the Meeting 380 Benefits of Conference Planning 381 Collaboration 382 Preparing to Present Your Case 383 Making the Presentation 383 Sample Presentation 384 Follow-Up to Meeting 385 Summary 385 Exercises: Planning 386 Exercise I: Developing a Service Directory 386 Exercise II: A Simulated Planning Meeting 386

Chapter 22 Making the Referral and Assembling the Record 387

Introduction 387 Determining Dates 388 Sample Referral Notification Form 389 The Face Sheet 390 Summary 392 Exercises: Assembling the Record 393

Chapter 23 Documentation and Recording 395

Introduction 395 The Importance of Documentation 396 Writing Contact Notes 396 Labeling the Contact 398 Documenting Service Monitoring 398 Documentation: Best Practice 399 Government Requirements 402 Do Not Be Judgmental 402

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Contents xi

Distinguish Between Facts and Impressions 403 Give a Balanced Picture of the Person 404 Provide Evidence of Agreement 404 Making Changes to the Plan 404 Summary 404 Exercises: Recording Your Meeting with the Client 405 Exercise I: Recording Client Contacts 405 Exercise II: Using Government Guidelines to Correct Errors 411 Exercise III: Spotting Recording Errors 411

Section 6 Monitoring Services and Following the Client

Chapter 24 Monitoring the Services or Treatment 413

Introduction 413 What Is Monitoring? 414 The Financial Purpose of Monitoring 414 Follow-Up 416 Collaboration with Other Agencies 416 Advocating 417 Leave the Office 418 Responding to a Crisis 419 Summary 420

Chapter 25 Developing Goals and Objectives at the Provider Agency 421

Introduction 421 Client Participation/Collaboration 422 Make Objectives Manageable 423 Expect Positive Outcomes 423 Objectives 425 Combining Goals and Treatment Objectives 426 Finishing Touches 428 Review Dates 429 Vocabulary 430 Summary 432 Exercises: Developing Goals and Objectives 432 Exercise I 432 Exercise II 433 Exercise III 434 Exercise IV 436 Exercise V 437

Chapter 26 Terminating the Case 439

Introduction 439 A Successful Termination 440 The Discharge Summary 443 Examples 444 Summary 447 Exercises I: Termination of a Middle-Aged Adult 448 Exercises II: Termination of a Child 448 Exercises III: Termination of a Frail, Older Person 448 Exercises IV: Organizing the Record 448

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xii Contents

Appendix A Ten Fundamental Components of Recovery 449

Appendix B Vocabulary of Emotions 451

Appendix C Wildwood Case Management Unit Forms 454

Appendix D Prochaska and DiClemente’s Stages of Change Model 487

Appendix E Work Samples 490

Appendix F Grading the Final Files 496

Appendix G Information for Understanding DSM IV TR Diagnoses 499

Appendix H Case Manager’s Toolbox 506

References 515

Index 518

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In a small nonprofit agency handling cases of domestic violence, a woman answers the phone. She assesses the caller’s concerns, accurately notes the caller’s ambivalence on the inquiry record, and readily connects the caller to the person most able to assist.

In a mental health case management unit a new worker listens with interest to the other case managers, the psychologist, and the psychiatrist discuss the possible diagnosis for a new client of the agency. The worker is able to understand the conver- sation as the group talks about the DSM IV TR diagnosis and the new DSM 5 diagnosis.

Down the street a young man acting as a case manager in a substance abuse detox center handles intake calls from physicians’ offices. He competently notes the main concerns for incoming patients and asks the questions he knows will give him information that doctors and therapists will need later as they work with these new admissions. His notes are clear and useful.

How long did it take these people to acquire these skills? Did they acquire this ability well after being hired in a social service agency, or did they arrive able to handle case management tasks competently?

Purpose

For me and for students, the issue has been how we can teach the social services skills that will promote their walking from the classroom into the social service setting with confidence. How can we be assured that students, often steeped in sound theoretical knowledge, will be able to fill out an inquiry form or make a referral effectively?

It is important to teach these practical skills. In addition, it is important to equip students with the vocabulary and methods used by more advanced professionals in the human service field so that upon entering the field students are prepared to engage in meaningful discussions around client issues. Although entry-level individuals would not usually give a DSM diagnosis, it is useful for individuals entering the field to be knowledgeable about what such a diagnosis is and what is meant by an Axis I or Axis II diagnosis or how diagnoses are given using DSM 5. In this way, conversations among professionals will not be misunderstood.

Today individuals with a sparse education or with recent college degrees are find- ing themselves thrust immediately into roles for which they have had little formal training. It is crucial, therefore, to find a method for teaching the actual human service experience at the entry level. Fundamentals of Case Management Practice: Skills for the Human Services, fifth edition, seeks to provide that experience in a thorough, step-by- step process that leads the reader from intake through monitoring to termination.

Preface

Preface xiii

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New in the Fifth Edition

New material has been added to this fifth edition to bring the textbook up to date. Added to this edition:

• Current terms are used throughout • Information on the DSM 5 and how entry level individuals can use this • Recent changes to HIPAA • Expanded Appendices to include material helpful in completing exercises in the

text, a safety planning tool and a case manager’s tool box with information to assist in assessment and disposition.

• A clear look at case management as a process • A discussion of how the size of a caseload affects service • Ethical considerations for those working in the field of substance abuse • A discussion of the differences among moral, ethical, and legal behavior and how

violations are addressed • More information on the importance of mandated reporting • Expanded treatment of the ecological model • Broader section on empathy and more recent findings on empathy • An extensive feelings list in the appendix for use in various exercises • Differences between confrontation and an exchange of points of view • Enhanced discussion of motivational interviewing and why this is useful • More detail on the significance of the first interview • There are fewer chapters as some material has been combined in single chapters

In addition, a considerable number of smaller items and changes specifically request- ed by our reviewers were added to the textbook.

Fundamentals for Practice with High Risk Populations (Summers, 2002) has been published as an adjunct to this text, giving students information and scenarios on populations in which they are interested or with whom they intend to work. Chapters cover topics such as case management with children and their families, survivors of rape and violence, older people, issues with drug and alcohol dependence, and men- tal illness and developmental disabilities. Each chapter features information about specific populations and provides exercises and intake forms. This textbook also con- tains a set of forms that can be copied (see Appendix C). These forms can be found on CengageBrain. Taken from actual social service settings, they give the reader an opportunity to practice accuracy and skill in handling social service forms and records and in organizing information.

If you do not wish to cover all of the populations discussed in the text on high-risk populations and instead want to focus on specific populations, you can order individual chapters from Fundamentals for Practice with High Risk Populations (Summers, 2002). Please visit http://www.textchoice2.com/ to view chapters online and to build your custom text. You can pick chapters about specific populations and create individualized booklets that you can bundle with this text. If you would like more information about custom options, please contact your local customer service representative. You can locate your representa- tive by using our rep finder at http://custom.cengage.com/.

xiv Preface

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Format

For each chapter in the textbook, basic information is laid out, followed in most chap- ters by many exercises that prompt the reader to handle real issues and practice real skills. Each of the chapters on case management describes one of the case manage- ment responsibilities followed by exercises to practice applying the information. As readers progress through the text, they gradually assemble files on specific cases. Stu- dents can create and monitor believable fictional clients using one of the high-risk populations discussed in Fundamentals for Practice with High Risk Populations (Sum- mers, 2002). Classroom discussions about these cases and the best disposition for each of them are not unlike the discussions that occur every day in a variety of social ser- vice settings.

Organization of the Textbook

The organization of the textbook follows a logical progression, beginning with the most basic foundation for good practice, moving to discussions on attitudes, followed by how the student will talk to others effectively. The second half of the book fol- lows a similar process, beginning with the person’s first contact with the agency and the assessment and planning process through all the case management procedures to termination.

In Part One, “Foundations for Best Practice in Case Management,” readers are introduced to important foundation pieces for this field. A definition of case manage- ment and how it is central to social services, ethics and ethical issues, and the impor- tance of the ecological model in assessment and planning give readers an introduction to professional basics.

In Part Two, “Useful Clarifications and Attitudes,” readers are invited to exam- ine what in their thinking will impede effective helping in the social service setting. Beginning with issues of cultural diversity and moving to the role of personal attitudes and boundaries, this part concludes with information and exercises related to deter- mining who owns the problem. Each chapter in this part contains exercises encourag- ing readers to examine realistically their own attitudes and judgments.

Part Three, “Effective Communication,” begins by introducing the reader to good and poor responses, with exercises that help students see the consequences of poor communication. Chapters on listening and responding, asking questions, bringing up difficult issues, responding to emotions, confronting problematic behavior, and disarming anger are included. Included is a chapter that gives an expanded examination of some of the techniques and ideas related to motivational interviewing. The section ends with a chapter on the effective application of what students have just learned and exercises designed to have students practice all the communication skills in order to smooth out the communication and allow it to become natural and responsive.

In Part Four, “Meeting Clients and Assessing Their Strengths and Needs,” readers begin to take inquiries for services. Forms are provided that ask for basic

Preface xv

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information, teaching the student what is important to find out in that first call. This section also includes a chapter on preparing for the first interview, helping the reader become sensitive to issues that clients might have at a first meeting. A chapter on social histories and assessment forms teaches students how to use these to assemble relevant information. Introductions to the DSM and to the mental status examination allow the reader to become familiar with the vocabulary and the information most important to other professionals in the human service field. Students are encouraged to begin noting how a person seems to them at the time of contact. The chapters and classroom discussions will help students pin down what is important to note. In this section, readers also practice completing release of information forms for the clients they have developed in the classroom setting, mastering which records are useful and which are not.

Part Five, “Developing a Plan with the Client,” allows readers to further develop a plan for those clients for whom they have created phone inquiries. Here, individually or in planning teams, according to the instructor’s process, students develop realistic plans for their clients. A chapter is included instructing students on how to prepare for and participate in team planning. In the final chapters, students refer cases to provid- ers of services and learn about documentation and recording.

Part Six, “Monitoring Services and Following the Client,” is the final section, and the section begins with a chapter on monitoring services and treatment. Students switch to the role of a worker in the agency of a provider of service and take the gen- eral goals given them by case managers and develop specific goals and objectives to be accomplished within stipulated time lines. Here students learn how to develop attain- able goals for their clients. In this part, readers also learn the importance of monitoring cases from a case management perspective and how to terminate the case. Numerous documentation exercises provide opportunities for students to begin writing profes- sional notes and keeping good records.

Supplements Accompanying This Text

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xvi Preface

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MindTap MindTap for Counseling engages and empowers students to produce their best work—consistently. By seamlessly integrating course material with videos, activities, apps, and much more, MindTap creates a unique learning path that fosters increased comprehension and efficiency.

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Preface xvii

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To the Students

It is always a challenge to know what skills and information you will need on the first day of your first job. Even when you are already working in the field and managing many of the tasks well, you often do not know for certain why agencies choose to do things one way as opposed to another. This textbook seeks to empower you to func- tion competently and to know why you are proceeding or should be proceeding with clients in a particular way.

In Fundamentals of Case Management Practice, you will follow a specific series of steps, beginning with what you are thinking and how to incorporate ethics into your thinking in client–worker relationships, continuing through your communication with clients, and ending with your putting together hypothetical case files and managing those hypothetical cases.

Throughout the course you will find yourself in discussions with others about possible treatment or service plans or the dynamics of a person’s situation. Use these discussions to learn more about collaboration and to increase your ability to participate in the same sort of discussions in the agency where you will work.

Many students have taken this textbook to work with them and have found it both useful and realistic. Students have contributed their experiences on the job to make this textbook replicate as nearly as possible the issues and concerns you will encounter in your work with other people.

Further, in developing your hypothetical clients, you may want to refer to Fun- damentals for Practice with High Risk Populations (Summers, 2002). In that textbook, six populations commonly served by social services, such as those associated with domestic violence, substance abuse, or mental health issues, are detailed so that you will be very familiar with their issues and likely problems. It is also possible to purchase individual chapters from that textbook on the population or populations that interest you. Each chapter will give you information on common problems, diagnoses, medications, treat- ments, and other considerations such as legal issues or common medical problems each specific population often experiences. See the instructions on how to order specific chapters in the earlier section of this Preface titled “New in the Fifth Edition.”

To the Instructor: Suggestions for Using This Text

This text can be used to take students step-by-step through the case management process outside of the often harried and pressured atmosphere of a real social service agency. When the student is ultimately confronted with the actual situation, the rou- tine and expectations will not be new. Chapters are broken down into each step in the case management process. Readers progress according to their skill levels, finally cre- ating cases and caseloads with you acting as the supervisor, much as a supervisor would act in an actual agency. Without the urgency, you will have time to let students look up

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information, discuss possible diagnoses, and develop sound interventions under your guidance. For example, exercises on the DSM and on the mental status examination have a number of possible answers. Your discussion with your students, similar to the discussions that take place in agencies about these possibilities, is more important than the actual answers that are chosen.

Most chapters include exercises to help students practice their skills. Often several versions of the same exercise are provided. It is useful to students to begin in small groups to address the issues posed in the exercises. Their discussions and the ideas and concerns they bring back to the larger class are consistent with discus- sions held in social service agencies. Later, versions of the exercises can be used as tests, or you can go back to them at a later time to make sure students continue to practice their skills.

It is extremely worthwhile for students to apply the skills described in this book to specific populations. To do this, you can use this book in conjunction with my other book, Fundamentals for Practice with High Risk Populations (Summers, 2002). After stu- dents have read the chapters on the specific populations you have assigned or on those that are most interesting to them, they can create a fictional “typical” client that they can then walk through all the exercises from intake to termination. Case notes would reflect the common problems encountered by the population, and intake would de- scribe a common reason for seeking services among people in this population. This gives students a good beginning look at how cases come in and unfold while clients are receiving services.

Details on six high-risk populations are provided in Fundamentals for Practice with High Risk Populations (Summers, 2002). A detailed chapter on children and their families gives students information on how to include others involved in the child’s life and how to coordinate all the various entities with whom the family interacts. Another chapter focuses on domestic violence and rape, including how these issues affect children.

A third chapter looks at substance abuse and includes the common social and medical issues that arise for this population. This chapter also includes the com- mon challenges this population presents to case managers and gives tips for how to handle these. Mental health and intellectual disabilities each are featured in chap- ters, giving common problems and issues, diagnoses, and treatments. Finally, there is a chapter focusing on aging that includes both medical and social issues for this population. All the chapters include an assessment form for that population taken from actual agencies that work with that population, and all the chapters give the most typical diagnoses and medications used with each population. Where a popula- tion has special considerations the student should know, these are included as well. For example, in the chapter dealing with issues most likely to affect women, there is a discussion of how women’s programs and agencies differ in their approach to cli- ents from other social service agencies. To order specific chapters related to specific populations, see instructions in the earlier section of this Preface titled “New in the Fifth Edition.”

Preface xix

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Benefits and Advantages

This material has been used in my own classroom for 30 years and has been updated to meet current social service trends and changes. Students have commented that using this text is like walking from the classroom into the social service setting with very little lost time in learning the actual process. Instructors teaching the practicum course have used the word empowered when describing what this text has done to give students confidence and skill in their first encounter with a social service position. Employers as well often contact me to say how well prepared students are who have used this textbook.

Three positive features of this textbook make it especially useful in preparing students to work in this field:

1. The text gives very basic information a person needs to handle each of the tasks described. Theoretical information can be found in many other places, and thus the concentration and focus are on what is important to note, think about, docu- ment, and pass on in each step of the human service process.

2. Numerous exercises create very real situations for students to consider and han- dle. These exercises are based on real experiences taken from my 23 years of practice in human services and from the experiences of many others who gra- ciously contributed to this book. Doing the exercises and participating in the classroom discussions that follow will expose students to an extremely broad range of possible circumstances and difficulties in the field.

3. The book contains forms that give students an opportunity to practice compil- ing information at various times throughout the management of the case. These forms can be copied and used to create files on clients developed by the stu- dents. Using each form a number of times gives students practice in preparation for real clients in real social service settings.

These features, when taken together, create a nearly realistic social service setting in the classroom, giving the instructor many opportunities to strengthen student skills and sensitivity.

In addition, Fundamentals for Practice with High Risk Populations (Summers, 2002) supports students with applicable details and considerable information on various at- risk populations. This textbook acts as a reference so that the hypothetical clients students develop are real with entirely likely problems. Students can use the material found in this supplemental textbook to develop realistic clients, create useful service plans, and make appropriate referrals.

Acknowledgments

As with each edition of this textbook, I could not write such a realistic work without the wonderful help of the staff at the Dauphin County Case Management Unit. Always ready to give their time and support, they have answered important questions, clarified new national policies, and brought enthusiasm to the writing of this book.

xx Preface

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I particularly want to acknowledge the help of Mathew Kopechny, former Executive Director who went out of his way to see that I had access to what I needed to make this textbook current. I am grateful for the time and useful examples provided by Michelle Beahm, who allowed me to shadow her for the preparation for this edition. In addition, I want to express my gratitude to Kim Castle, clerical supervisor, who has worked with me on each edition of this book to clarify issues and give me details I might otherwise have missed. Just knowing she was there to help made writing this book much easier. Thanks go as well to Joel Smith, intake case manager, who graciously allowed me to observe an intake with a client during my time observing at the Dauphin County Case Management Unit.

I am particularly indebted to Charles Curie, MA, ACSW who has always given time to discuss issues related to the textbook. He headed the Pennsylvania Office of Mental Health and Substance Abuse Services, making Pennsylvania a leader in innovative services and procedures. Appointed by President Bush to head the Substance Abuse and Mental Health Services Administration (SAMHSA) he instituted state-of-the art prevention and treatment ideas nationally. His support of this textbook has ensured the teaching of best practices.

At the Dauphin County Executive Commission on Drugs, Alcohol and Tobacco, I want to thank John Sponeybarger for his help in formulating realistic plans and services. I am grateful to the late Ruby Porr for her ideas based on her work as a service provider and to Aimee Bollinger Smith, Karen Polite, Wendy Bratina, and Carol Reinertsen who use this textbook and had teaching suggestions for additions to the text.

I deeply appreciate the support and information my husband, Martin Yespy, con- tributed to this work. His unfailing assistance and encouragement of these textbooks and the useful material and information he brought from the field of crisis intervention have enhanced this work.

I especially want to thank my editor, Julie Martinez, who has given me support, guidance, and a good dose of humor when needed. She has always been there when I needed help and her advice greatly enhanced this work.

The two students, Danica Zirkle and Keyanna Watkins, who organized and then participated in the videos deserve considerable gratitude for all the work they did to keep everyone on track. The students who participated in the vignettes, writing and rehearsing their work also deserve my gratitude for all their hard work. They are Catherine Wrighstone, Tom Moulfair, Sean Taney, Michele Anthony, and Alison Kilgore. Many thanks to Michelle Beahm again for participating in the videos and giving her ideas to make the vignettes more realistic. Brian Peterson and his crew from Motion Masters provided considerable direction and made the filming smooth and effortless. My thanks to all of them for the time they spent with us.

Preface xxi

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I would also like to thank the reviewers of this textbook for their very helpful comments:

Susan M. Scully-Hill, Assumption College

Barry Yvonne, John Tyler Community College

Paula Gelber Dromi, California State University, Los Angeles

Alyssa Forcehimes, University of New Mexico

Monte Gray, Bronx Community College

Karen Guerrieri, Kent State University, Salem

Richard Jenks, Tillamook Bay Community College

Lee Ann Rawlins, University of Tennessee

Their ideas and suggestions greatly strengthened this work.

xxii Preface

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Chapter 1 Case Management: Definition and Responsibilities 1

Case Management: Definition and Responsibilities

Introduction

Case management is one of the primary places in human service systems where the whole person is taken into account. Unlike specific services, case management does not focus on just one problem but rather on the many strengths, needs, and personal concerns a person brings.

For example, an elderly person may be referred to Help Ministries for a voucher for fuel oil because it has been unusually cold and the elderly person has been unable to pay for the additional oil needed to warm his home adequately. In this case, Help Ministries is concerned with his fuel oil need and the warmth he will need to stay in his home during the winter. That is their only concern with regard to this man.

The case manager, on the other hand, is concerned with the person’s need for fuel oil, with his desire to move into public housing for the elderly in the spring, with what resources he has among his children, with his recent slurred speech indicating a possible stroke, and with his need for meals-on-wheels. The case manager is aware that there is a neighbor who can look in on him daily, that the man has ties to a church, and that he receives Social Security but little other income. She knows he has a sense of humor, goes to bingo once a month, and should be fitted for a cane.

Case management is a process for assessing the individual’s total situation and addressing the needs and problems found in that assessment. As a part of this pro- cess, the person’s strengths and interests are used to improve the overall situation wherever possible. The primary purpose for case management is to improve the qual- ity of life for your client. This might mean more comfortable or safer living arrange- ments, or it might require psychiatric care or medication for diabetes. Another major purpose of this activity is to prevent problems from growing worse and costing more to

C h a p t e R 1

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2 Section 1 Foundations for Best Practice in Case Management

remedy in the future. In the situation of the elderly man just described, we find that the meals-on-wheels program will deliver a certain standard of good nutrition, pre- venting malnutrition and costly medical bills in the future. By getting the man a cane, we may be preventing falls that would shorten his life and cost much more in medi- cal bills to repair his injuries. If we enlist the neighbor to look in on our client every day, we have provided a link between the man and his neighborhood. In addition, the neighbor can alert us to small problems that require our attention. In this way we have foreseen possible difficulties and taken steps to prevent them.

A History of Case Management

In the late 1800s, a formal attempt was made to organize the delivery of services to people in need. Initially the Charity Organization Society took control of this approach, making the collecting of information and the delivery of services more systematic. In the course of its work, the society developed casework as a useful method for tracking needs, progress, and changes in each case. As people had more needs and problems beyond poverty, the need to coordinate these services became important to prevent duplication. Casework also was employed as a means of tracking and using scarce resources to the best advantage. In the 1960s, the process of deinstitutionalization meant that individuals once housed in institutions were now placed in communities where they needed considerable support to live more independent lives; as a result, casework became ever more important for a larger number of people.

In the 1980s, the term caseworker evolved into the term case manager, and these managers took on greater responsibility for managing resources, finding innovative supports, and coordinating services. Agencies began to use case management as a pro- cedure to assess needs, to find ways to meet those needs, and to follow people as they used those services. In addition to keeping an eye on how scarce resources were spent, case managers were charged with taking a more holistic approach to their clients, looking at all their needs rather than addressing only those that brought the person in for assistance. As part of this charge came the directive to develop individualized plans, plans constructed specifically for that person and not a cookie-cutter approach to supplying services.

Today case managers are seen as a significant service in almost all social service settings and are viewed as the most important way to prevent relapse, track clients’ needs, and support progress toward good health.

Language in Social Services

Language in the social services is a funny thing. After a word is adopted to describe people who use a service, that word becomes pejorative over time and a new word meaning the same thing is sought. In social services, we have gone from labeling peo- ple patient (which implied people seeking services were all sick in some way) to client and finally to consumer.

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Chapter 1 Case Management: Definition and Responsibilities 3

Client was meant to denote that the person was being served by a case manager in a relationship much like a lawyer–client relationship. This originally conferred an obligation on the part of the case manager to give good service to someone paying, in some manner, for that service. However, as with all words describing people who use social services, the word client developed a negative connotation and the word consumer was increasingly used instead. Consumer also implied the person was paying for good services from the case manager.

With the Recovery Model (Appendix A) developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the emphasis on partner- ships between case managers and the people seeking services, those words are no longer considered appropriate. The concern is that these words denote a difference in status between case manager and those they serve. Thus, in recent years, the terms client and consumer have given way to person or individual, and in many cases no term is used but rather the person’s name is used instead.

In this textbook, we subscribe to the idea that case managers and the people they serve are in a partnership to which each brings a certain degree of expertise. In your work, we strongly encourage you to drop the use of the words consumer and client and adopt what is seen as the more respectful terms of individual and person.

However, having said that, there are places in this textbook where using person and individual alters the meaning of the sentence and the point that is being made. For that reason, in this textbook, we need to use client to denote a person seeking professional services from a professional case manager in order for the point to make sense. This is in no way meant to diminish the person who does seek service, but rather to make our points more coherent.

Why We Use Case Management

Case management serves two purposes. First, it is a method for determining an individualized service plan for each person and monitoring that plan to be sure it is effective. Second, it is a process used to ensure that the money being spent for the person’s services is being spent wisely and in the most efficient manner.

The money you oversee in consumer care may be public money, such as the money that comes from the state to a county to administer mental health services or substance abuse treatment. It may be money that is provided by insurance compa- nies for services to a policyholder. It may be money provided directly to an agency from either of these sources for the care of a client. Sometimes organizations, such as United Way, divide the money they have raised among various community agen- cies. These organizations then employ case managers to make certain the most effective use is made of that money. It is therefore the case manager who deter- mines what is needed and how to prevent needs and problems from escalating. It is the case manager who, in collaboration with the consumer, determines what services should be authorized with the existing money. It is the case manager who then follows the consumer and the consumer’s services and treatment to keep the plan on track.

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4 Section 1 Foundations for Best practice in Case Management

Case management is more than looking out for another entity’s money. It is also the most efficient way to make certain a person receives the most individualized plan for service and treatment possible. To ensure that this will be done, case management responsibilities have been broken into four basic categories of service: assessment, planning, linking, and monitoring. These four activities constitute the case manage- ment process. Let’s look at these categories in the order in which they are usually accomplished when working with a person.

Case Management as a Process

Assessment

The first case management task is assessment. A good assessment is the foundation for understanding the problem and informing and guiding the treatment and ser- vices. Therefore, it must be done with care. This is an initial assessment, meant to be comprehensive and thorough. For that reason, it covers many different aspects of the person’s life in an attempt to develop an accurate profile of the individual and the individual’s problem.

There are several kinds of assessments. In some cases you will be asked to do a social history (see Chapter 16). Here you ask a series of questions, and as the person answers, you construct a written narrative. Social histories usually have a number of elements that you are to assess, and each is given a subheading within the narrative. For example, current medical condition, living arrangements, relationships, and work experience are all important. In another kind of assessment, you may be given an intake assessment form that lists all the questions you are to ask and gives you a place to note the answer. Each of these assessment procedures attempts to be comprehen- sive. Each seeks to assemble a considerable amount of material about the person and his or her problem.

The first thing the case manager does is assess the initial or presenting problem. Why did this person come into the agency, and what is the person asking for? Here case managers look at the extent to which problems have interfered with clients’ abil- ities to function and care for themselves. Does this problem interfere with work or with relationships? It is especially important to note the background of the problem, how long it has gone on, and how it started. In addition, the reasons the person is seeking help now are important.

Case managers include an opinion about what possible problems might arise for this person in the future and what plan might be put into effect with the person to prevent these problems. Your opinions about potential future problems are formed as you listen to consumers describe their situations. Will the individual be likely to be around people who encourage him to drink? Does she have a medical problem that needs attention because it exacerbates her depression?

A discussion of the problem uncovers the person’s needs and how he or she views those needs. Case managers look at the overall situation and consider what that person needs to bring stability and resolution to his or her life and problem. Are there

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Chapter 1 Case Management: Definition and Responsibilities 5

needs that can be addressed that will relieve the problem, or at least alleviate it to some extent?

In every assessment with an individual, you will begin to learn what strengths the person has that you and he may draw upon to resolve the current problem. Does your client have an advanced degree, a particularly supportive family, a number of friends, a sympathetic boss, a particular skill? An assessment should never be just about the person’s problems, but should also include the strengths the person brings to the problems and the strengths you see in the person’s environment.

As you take the information from the consumer, you are, through your observa- tions, also evaluating the person’s ability to think clearly and to understand options, and the person’s general mood. You are seeking to understand the extent to which the person understands the origin of their problems. Chapter 18 discusses in more detail something called the mental status examination. This is not a series of questions but rather your astute observations of the individual during the interview.

At the end of your assessment document, you will be asked to express your assessment and recommendations. Here you will summarize briefly the problem and the person’s ability to handle the problem, noting the person’s strengths and needs. Then you will give your own recommendations for service or treatment. Recommen- dations are generally worked out with the consumer as you learn what it is the person is seeking and share with that person what you have to offer.

To summarize, in an assessment you are exploring and evaluating the following:

1. The initial problem and the background to that problem 2. The person’s current situation 3. The person’s background in areas such as education, relationships, work history,

legal history 4. What the person needs to make life more stable and to resolve the current

problem 5. The strengths, including those the person brings to the problem and those in the

person’s environment that would be useful in resolving the situation 6. Observations about how well the person functions cognitively and any seeming

mental problems you have noted 7. Recommendations for a service or treatment plan for the person

A good assessment is the foundation for the development of an individual plan for service or treatment. It delineates what essential services should be provided for individualized treatment. The assessment also establishes a baseline detailing where the person was when he or she entered services and against which you can measure progress.

Planning

After the assessment, you will be expected to develop an initial plan with the client that is comprehensive and addresses all the issues raised in your assessment. This plan should show incremental steps toward improvement and expected outcomes.

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6 Section 1 Foundations for Best practice in Case Management

As a case manager, you cannot plan well with the person unless you are thoroughly aware of the services, social activities, and resources in your community.

Formal Agencies Every community has social service agencies that serve specific needs. The best case managers seem to know all the good places to send people for the services those people need. Some communities and counties have more services than others, but in most locations, agencies are serving children and their families, older adults, individuals with substance abuse problems, individuals on probation, women in abusive or rape situations, and individuals with mental illness or intellectual disabilities. Generally, case managers need to learn about other services as well, and the information and phone numbers for these services should be readily available to you when you practice. You will want to gradually develop contacts in these places so that your referrals are smooth and problems are quickly handled.

Begin by knowing what formal agencies are out there to help with a particular issue. For instance, if your client has a mental health problem, you might refer him to an agency that specializes in mental health treatment. The staff at that agency is familiar with medications, diagnoses, and treatment alternatives for mental health problems. Another individual may be elderly and in need of protective services because you suspect she is being physically abused by her family. You would refer her to a specific agency that offers protective services to older people. A third person may have intermittent problems with substance abuse and need services from an office where there is an intensive outpatient treatment program in the evenings. Knowing the agencies in your community and the formal services they offer is a good foundation.

Generic Resources Good planning is not limited to formal agencies, however. Learn about resources that are available for common problems we all have. Not every problem a person with an intellectual disability has will need to be treated by agen- cies set up exclusively for individuals with intellectual disabilities. For example, a woman with an intellectual disability, grieving the death of her mother, was welcomed into a grief support group at the local church and given much support. In another example, a child with academic problems in school was referred to the free tutoring at a local church. An older person who needs more social contacts might be referred to a senior center where many older people go for social and recreational opportunities. In the previous examples, the older person suffering abuse may also need the services of your local district attorney, and the person with a substance abuse issue might need medical care from a general practitioner and a public defender for pending charges of disorderly conduct. These are all services anyone can use. Knowing how to access them for your clients is important.

Support Groups and Educational Seminars Other resources often overlooked are support groups and educational seminars. For example, you may have referred the family of a child you are working with to formal family therapy sessions. In addition, you would look at support groups where parents dealing with similar problems can get together to support each other. Further, you might find a workshop on parenting skills

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Chapter 1 Case Management: Definition and Responsibilities 7

that would greatly benefit this family, and you would tell them about the workshop and strongly encourage them to attend. A man on probation might benefit from a workshop for job readiness or a support group for ex-offenders attempting to make significant life changes. A woman who is struggling with years of sexual and physical abuse might benefit from a support group of other women facing similar issues.

These resources augment your own efforts and those of formal services and give consumers additional support and information. Often they are free or at very little cost. What your clients gain from their experiences in such groups reinforces the other services you are arranging.

Peer Support A relatively recent trend is to use peer support wherein a former client who is doing well is hired by an agency to support others on the road to recovery and life changes. It might be individuals who were able to turn their lives around after a period in juvenile detention and now are supporting others coming out of juvenile detention to do the same thing. It might be someone who has had a mental illness and is now helping others who are recovering from their own mental illness. And, of course, in substance abuse, Alcoholics Anonymous (AA) has always used that model of one person in AA helping another. The idea is based on the fact that not all profes- sionals know what it is like to experience some problems firsthand. The peer support person is able to say he has been there and can show another how to resolve the issues with firsthand practical information.

Individuals whose functioning is impaired might benefit from a peer support person who can help them function better educationally, socially, or vocationally and may even become involved in helping them with issues of self-care. Much like case management, the peer support person ascertains that the consumer will accept peer support and then works with that person to set realistic and meaningful goals the two can approach together. Good peer support helps people formulate the small action steps needed to move toward the goals the two have identified together, and the peer support person can be there with advice and ideas if the action step doesn’t work very well. As a case manager, you will use peer support when a person needs more sus- tained time than you can give, and the support will significantly help the person move toward recovery.

Informal Resources and Social Support Systems You will also want to be aware of social activities your clients might enjoy that would keep them involved in their communities. Perhaps one person likes to work on models and could become a member of the model railroaders club. Perhaps another genuinely likes people and enjoys being with them. This person might do well as a member of the Jaycees.

People do better living in a community in which they have healthy social support systems. A social support system refers to the kinds of supports most of us have in our communities such as Lions Club, a church, or volunteering on specific community projects. All of us need to feel we are a part of the place where we live, but many people do not have the skills to interact with others and find useful activi- ties on their own. As a case manager, it is your responsibility to integrate your con- sumer into the community if this is a need. Find social clubs, churches, and groups

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8 Section 1 Foundations for Best practice in Case Management

that pursue similar interests, and help your client make contact with those people. The more contacts the person has and the more useful activities the person engages in, the more support the community can give.

A particularly touching example of the use of informal social supports occurred in a small town in which the firehouse was located just around the corner from a group home for five older men with mental health problems. They had been institutional- ized for most of their lives, spent years on medication, and had the common long-term side effects that can develop. One of the men, Nick, wanted to be a fireman, so the case manager connected this man to the fire company around the corner. The men at the firehouse made Nick a part of their everyday routine. Nick helped roll hoses, swept floors, and took his meals with the men. Nick was included in meetings and made decisions about the dinner menu. He became such a part of the fire company that when he died suddenly of cardiac complications the men were deeply saddened. As a tribute to Nick on the day of his funeral, the procession from the funeral home to the cemetery was led by a number of fire trucks, beginning with the trucks from Nick’s home station and including some from neighboring communities. This was an excellent example of using social supports to give a person a valued place in his community and a sense of doing something worthwhile.

Case managers often fail to use these valuable informal resources for several reasons. They may feel that their client cannot handle being with ordinary people in ordinary settings. This is often based on the case manager’s attitude about the per- son’s disability and is often quite erroneous. Having consumers in small numbers in social activities or organizations that give them an opportunity to practice strengths is an invaluable experience for everyone concerned. Another reason a case manager might be reluctant to place a consumer in a community social group might stem from the case manager’s perception that people in such groups do not want to be bothered with people who have disabilities. In some cases, this assessment is correct, but in others it is quite the opposite. Many organizations are set up to provide service and perceive this as an opportunity to grow and serve the community.

Doing your homework pays off. You cannot rely on suppositions and specula- tions. Know what is available in your community and have places in mind that would serve your consumers as the need arises. Meet people and talk to them about what you would like to have available for your clients. Gradually, you will develop a list of people and places that welcome your clients and provide the specific experiences and support you are seeking. Your task is to have many resources you can use at your fingertips when developing plans for your clients and to continually be developing new ones in your community.

Creating an Individualized Plan After you have worked with people to determine where the problems are and what areas need attention, you will also know about the supports and other resources people have in the community and among their family members and friends. You will know what they do well and what interests them most. Each person will be different.

As you go about designing the plan with the person, you will place in that plan elements that take advantage of the client’s strengths and supports. In addition, you will

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Chapter 1 Case Management: Definition and Responsibilities 9

address those problems most outstanding or immediate for that client. Each person has a different set of strengths, life circumstances, immediate problems, and personal goals. No two people view their situations in exactly the same way, so no two plans will be exactly alike. Each plan will be developed specifically for that individual client.

At one time, a small program for homeless women employed a part-time case manager for the children. Homeless women were given 2 years’ residence in apart- ments belonging to the program to work hard on getting an education or training, and a stable source of income. Many of them were distracted from this by concerns about their children. Still others had little time to think about what their children needed as they went about restructuring their lives. The county social services department gave the shelter a small stipend to hire a children’s case manager. The shelter hired a young woman who had just graduated from college. This seemed like an ideal choice. She was energetic, related well to the children, and was genu- inely concerned about each of them. In the next year, the program monitor from the county noticed two things. First, there seemed to be very little material on the children in any records. No individual plans could be found, and no assessments on each child appeared to have been done. Second, the children were all following much the same plan. All the girls attended gymnastics; all the boys were enrolled in Little League. On certain weekends, all the children, regardless of their age or interests, went to the zoo or to the circus.

After receiving repeated requests for individualized plans for each child and some guidance about how to create them, the case manager quit. She said, on departing, that she did not have time to sit and write up records, that the children had been “having fun,” and that the county was unreasonable. The county became more involved in hiring the second case manager, and this person was well aware of the importance of individualized planning.

In the first 6 months, two children began to get orthodontic work done, one received a scholarship to a private school, four boys went to Little League, one took violin lessons, and a third joined the swim team at the YMCA. Most of the younger children went to the circus and to the zoo. Most of the older children went on a bus trip to Washington, D.C., and half of them went to two symphony orchestra perfor- mances that winter. No child’s plan was the same as that of another child. Each child’s needs had been documented and addressed in some way, and each child’s strengths and interests were brought into play as the plans were developed.

In developing these plans, the case manager called all her contacts in the community. She asked two dentists to donate their time. She prevailed upon the symphony to give her the tickets for two performances. She went to a private school and talked to them about this particularly gifted child until a plan for financing the child’s education was worked out. She found a violin teacher and asked for 15 free lessons as a gift to the shelter. In churches, mosques, and synagogues, she got people enthused about helping the children whose mothers were working so hard to put a stable life together for their families. She looked at scout troops, church youth groups, and organized sports for possible answers to the children’s needs. In any number of cases, the plan simply involved the case manager helping an older child choose from among school activities and arranging transportation.

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10 Section 1 Foundations for Best practice in Case Management

This is what is meant by individualized planning. When it is done well and done creatively, your clients can grow and thrive.

Continued Assessment and Continued Planning In continued assessment and planning, as you follow the case, you will take into account changes the person may face. An example will illustrate this kind of planning, which you may be called upon to provide. Mary Beth has an intellectual disability and was assigned to you when she left a state-run institution for individuals with intellectual disabilities. When you did the intake assessment and planning, you determined that she would do better initially in a sheltered living arrangement for about a year. Because the goal is for her to move to an apartment of her own at the end of the year, your plan- ning should start well in advance of this move. This planning makes the transition easier for her and for you. There are no shocks and sudden surprises that might necessitate her need for hospitalization or a regression back to greater dependence on the agency.

You might begin by setting up services and activities with Mary Beth that involve her in her community. Mary Beth told you when you first talked to her of her interest in singing. The people at the institution said she loved music and sang well, although she could not read music. At the time Mary Beth came out of the institution, you could not find a good place for her to use her musical interests, but you noted this as a strength and kept your eyes open for an appropriate link. Now you have found a choir director at a small church who is willing to have Mary Beth sing with her choir. The church has numerous activities, and there are mem- bers who see to it that Mary Beth is included. In this way, you begin to prepare her for a move to more independent living. You seek and find a place for her to live not too far from the church, and you work with interested members to ensure that Mary Beth will have their continued help with transportation and inclusion in church activities.

You may think it best that Mary Beth has other social ties to her community as well. There is the Aurora Club, created by professionals just for people with some intellectual disabilities. This club is a place to go and meet others; and the club takes trips, goes bowling, and goes out to dinner together. You could refer her there; how- ever, you might decide that Mary Beth’s mild disability does not warrant her being limited to social activities only for individuals with intellectual disabilities. Instead, you might develop a relationship with a local women’s club, getting them to take Mary Beth as a member.

As Mary Beth makes an adjustment to being outside the institution, you look for a job placement. You make a referral to Goodwill, where she is able to develop her social skills, and soon she is hired by a local Wal-Mart as a greeter. All the while Mary Beth is away from the institution, you are meeting with her, assessing her progress toward independence, and planning for her to take a little more personal responsibility.

By the time Mary Beth moves into an apartment of her own, she has gained new confidence and many friends who connect her to the community. Her success is due in large measure to both your wise initial plan and your modifications of the plan as Mary Beth grew more independent.

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Chapter 1 Case Management: Definition and Responsibilities 11

Linking

Linking is the general term we use to mean connecting clients to people or agencies where they will receive the help or service they need. Once the plan is drawn up, the case manager links the person to the service, activity, organization or club, or people who will carry out the plan. When we connect the person to a formal agency we make a referral (see chapter 22) but, as noted before, we will link people to more than just formal agencies. Linking a client to a specific service requires care and skill on your part. You need to know the best service that will meet the individual issues and needs of your client.

Linking your client to a social service agency that provides a specific service— such as day treatment, drug rehabilitation, or groups for victims of violent crime—will require a written referral. You will state why you are making the referral, indicating the problem for which the referral is being made, and the goal that you expect as a result of your client’s contact with the agency. The referral will also indicate the amount of time you estimate it will take for the agency to reach this goal. The time limit is very important. It keeps treatment from becoming endless and unstructured. With a goal and a set amount of time in which to attain that goal, both the agency and the client are more likely to make the most of their time together.

Sometimes people can take advantage of services on their own. You might tell a client about the Aurora Club, for example, and the next week he may take a bus there and begin going to the club regularly, participating in activities and social events. At other times, you may have clients who are unable to take the first step and who will need you to accompany them or to arrange transportation for them.

In a formal social service agency, personnel at that agency will be able to support your clients in their programs and implement the goals and work on the issues you and your clients have identified as important. Some agencies with very fine programs or specialized services are small, which may require you to give more support to your client. For example, at New Start, a staff of three focuses on second-stage groups for victims of rape and domestic violence, and much of the work is done by volunteers. The success rate is excellent, and clients report a high degree of satisfaction with the agency. However, the small staff is not equipped to handle other problems that might develop while your client is in their group. If you refer a client to a group at New Start and your client has landlord problems between group sessions, the staff at New Start may not be aware of it in time to prevent an eviction notice. Even if they become aware of the notice, they will need to refer the client to you to resolve the matter be- cause of the limited staff time available to clients. On the other hand, at Riverview, a day-treatment program, nurses are aware of medication problems, social workers monitor progress toward goals, and staff can work to prevent eviction of a client, if that appears imminent.

On occasion you may find a service for your client at an agency that does not seem interested in serving her. Perhaps they are reluctant because your client has been ill recently or because the agency is not interested in her type of problem. The agency may accept the client into service with them to fill all their slots and draw down payment for services, but in reality they may give poor or no services. In such instances,

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12 Section 1 Foundations for Best practice in Case Management

linking becomes advocacy as you advocate for your client or on behalf of your client. In a situation like this, advocacy means you will attempt to seek the best services for your client, and you will insist that your client be treated fairly and with respect.

Beyond the formal agencies, however, we might choose generic services that require no formal referral or we might make connections with community social sup- ports where it is often completely unnecessary for the people there to be aware of your client’s status with your case management unit. Linking is about choosing all the best options that will support your client toward her goals and the stability she is seeking.

ASSIGnMEnt

Begin now to put together a resource book listing agencies and what they do, sup- port groups, and places where educational seminars and workshops are held for the general public. Collect them from the community where you expect to practice and keep the latest copy of social services agencies found in most telephone books.

Monitoring

After the plan has been made and implemented (meaning the referrals and links indicated in your plan have been accomplished), it becomes your responsibility to monitor the services given to your client. When a formal agency is holding a planning or treatment conference about one of your clients, you should be invited to attend. You should also receive written reports about your client’s progress and about the ser- vices given to him or her. If you do not receive reports at specified intervals from the agency, you need to contact them yourself on a regular basis.

Talking with another agency about the service they are giving your client is done for two reasons:

1. To be certain that the treatment or service you authorized for this person is in fact the treatment or service that is being given

2. To keep track of your client’s progress toward the goals you developed with the client and be aware of times when modifications and revisions in either the goals or the plan need to take place. Again, your assessment is on-going.

Less formal groups or institutions that are part of your plan should get a call or visit from you occasionally to monitor how the plan is working. Suppose that the neighbor offers to take your client, Bill, to church with her family every Sunday. In August, the family goes away for a month and does not make arrangements with anyone else to take him to church. He begins to feel lonely, and one day he goes to another church closer to his apartment. There he is extremely friendly to everyone, which seems to bother the minister and several members of the church. They decide he is “inappropriate” and call crisis intervention, whose team gets tied up going to the church and sorting out what happened. All of this could have been avoided if you had been able to have regular contact with the family who took your client to church. In

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Chapter 1 Case Management: Definition and Responsibilities 13

that case, you would have known of the vacation and could have requested that they find a substitute or could have found a substitute yourself.

If you have linked your client to a choir, the Lions club, or courses at the commu- nity college it would not be appropriate to check in with these entities, but it would be appropriate for you to check in with your client to see how these connections are working out.

Figure 1.1 outlines the knowledge base and skills needed for case management and offers some useful guidelines for you to follow in practicing case management.

Advocacy

Nearly everything you do in relation to your client is a form of advocacy. When you plan with your clients, you advocate for their voices and opinions to be heard. When you link your clients to specific services or activities, you advocate for the best place- ments and treatments for your clients. When you monitor your cases, you advocate for the goals you and your client have determined should be met.

There are other instances where you need to be able to stand up for your client or find the leverage in your community where clients’ rights or best interests will be supported. For example, suppose that your client has just left a drug rehab facility and is living on her own for the first time. She is in a small public housing apartment and is told she is being evicted along with a number of other clients because the building has been deemed unsafe. However, the city seems unable or reluctant to find other housing and your client can only afford subsidized housing. If you have met with your client to look at the options, and if you have met with your client and the public hous- ing officials and find them unwilling or disinterested in relocating your client, you may need to go with your client to see her state representative.

True advocacy in this case might involve your accompanying your client to a hearing, testifying on her behalf at a hearing, insisting that she receive a fair hearing, assembling the facts and putting them before a particular board, going to meetings with others whose clients will be affected, and even seeking legal aid.

In the chapters on communication, you will learn ways to communicate your con- cerns so that you do not come across as petulant and demanding. Nevertheless, many clients are not able to organize on their own behalf, defend themselves effectively, or know when they are being exploited or abused. Case managers have an obligation to monitor when their clients are at an extreme disadvantage and to advocate for these people in whatever way is appropriate.

Service Coordination

Service coordination refers to working with other agencies or systems in a person’s life. Many of your clients will be involved in other programs and systems, and each of these programs or systems may have a different plan for the person. Each of these plans may be headed more or less toward the same broad general goal, but their spe- cifics for the person are all different. Often the major and most significant role for the

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14 Section 1 Foundations for Best Practice in Case Management

Knowledge Base for Case Management

In order to do case management, you need knowledge of the following:

1. Individual and family dynamics (which you find in courses such as Human Development, Introduction to Psychology, Marriage and the Family, and Abnormal Psychology)

2. The relationship between and among social, psychological, physiological, and economic factors (as found in the ecological model, a theoretical basis for evaluating a person’s situation and needs)

3. The focus and policies of your agency 4. State and federal laws and regulations that affect your agency’s delivery of service 5. The vast array of community services and resources where you practice

Skills You Need to Be an Effective Case Manager

To be an effective case manager, you need the ability to:

1. Work effectively with people to promote their growth 2. Work collaboratively with people of various professions, paraprofessionals, the public,

and clients and their families 3. Identify what your client needs 4. Keep accurate and well-organized records 5. Allow the client to take leadership in planning services 6. Develop creative resources within your community to meet client needs

Guidelines for Case Management

Here are some useful guidelines in practicing case management:

1. Plan ahead. Plan before there is a crisis. Develop a plan that will prevent crises based upon what you learned about your clients in their assessments and what you can foresee happening in their situations if the issues are not addressed. Alleviate crisis- provoking situations.

2. Be accountable to your client and to the community. Do what you say you will do. Do it promptly. And carefully document what you have done.

3. Be optimistic about your client. Expect improvement and some degree of indepen- dence, and that is what you are most likely to get. Reinforce success, and never miss an opportunity to give positive feedback. Set up situations in which your client is likely to succeed rather than situations that are complex and tricky.

4. Involve your clients in all phases of planning. Let your people decide what issues and problems in their lives take priority. Get their opinions and feedback about services and about their plans.

5. Go where your clients are. Do not stay shut up in your office. Go out and see where your clients are interacting with others, and teach your clients new skills in the field where they will need them.

6. Promote independence. Show pride in the independence your clients demonstrate regardless of how small it is. Model independence, encourage independence, and teach as often as it takes the skills to maintain independence.

7. Develop a large number of resources and know how to find good ones for your clients. Know what formal agencies exist in your community and their focus. Look for and develop good social support systems on which you can rely. As you move about the community, look for new resources you can add to your list.

Figure 1.1 Knowledge base, skills, and guidelines for case management

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Chapter 1 Case Management: Definition and Responsibilities 15

case manager is to bring representatives of these different systems together, forming a team that collaborates with one another in supporting the client’s goal.

This is not as easy as it sounds. Communities and counties have numerous ser- vices, such as the school and other educational systems, mental health and the intel- lectual disabilities systems, the criminal justice system, a substance abuse system, and health care systems. These organizations often operate as though they are the only program with which the client is involved. Case managers who attempt to get every- one to work together are sometimes not welcome, and the program may be closed to outside input and collaboration with other agencies. However, coordinating the differ- ent services can enhance clients’ movement toward their goals. When coordination is not possible, a person’s goals can be impeded tremendously.

For example, Norita was a student at a community college and also a mother on welfare with one child. Because of her mental health problems in the past, her case manager at the mental health unit had facilitated Norita’s receiving welfare to sup- port herself while in school, and the case manager had worked with Norita to get her into school where she was an excellent student. Then the welfare worker insisted that Norita drop out of school and take a job readiness course as all single mothers on welfare were required to do. This demand came in the middle of a semester, and time and money would have been wasted if Norita was forced to drop out of school. The case manager worked with both the school and the welfare office to form a team working to support Norita in her movement toward financial independence.

At first, the welfare worker was not happy about working with the case manager. She was curt and unpleasant and stipulated that the rules for remaining on welfare meant that Norita would have to drop out of school and take a 7-week job readiness course. The case manager made an appointment to meet and brought an academic counselor from the college to the meeting. In this face-to-face context, the welfare worker began to soften and see advantages to Norita’s current plan. Norita was only one semester away from graduation after she completed the current semester. The college counselor stated that the counseling department was available to help with resumes and job searches. In fact, it was likely that Norita would be hired from her internship as she was going into a field with a high demand for workers.

Gradually, a team was formed, and collaboration around helping Norita become independent took place. In the end, each party felt the outcome was beneficial to its system. This last element is crucial when coordinating with other agencies and systems. To support the overall plan, each party has to feel that what is being agreed to will have a satisfactory outcome for the system he or she represents. In this case, both the welfare worker and the case manager met the goal for Norita to become independent and self-supporting. In addition, the case manager avoided duplication of services. If the college was showing Norita how to get a job and the welfare system was as well, there would have been duplication of services. What could have been competing systems and ill will became, instead, complementary services integrated around a specific goal and working together on Norita’s behalf.

You will not always be coordinating with other social services agencies. In one instance Meredith’s client, Phillip, believed he was employed by the Fresh ’N Save grocery store near his home. This was a delusion Phillip had held consistently for over a year. Phillip had gone to the store on numerous occasions, rearranging things

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16 Section 1 Foundations for Best practice in Case Management

on the shelves, helping shoppers with their bags and carts, and generally impeding some of the daily tasks at the store. On a number of occasions, Phillip was arrested for defiant trespass, and often he was escorted off the property by the local police. In one instance he was given a short jail sentence, but 6 hours after his release from jail he was back at the Fresh ’N Save. The case manager pulled together a team of people who previously had been working on their own to try to solve this problem. Present at the first meeting was the probation officer, the county mental health representative, a person from the police department, and the manager of the Fresh ’N Save. The ques- tion before the team was, “What resources do we need to resolve this problem and move Phillip to more constructive activities?”

Everyone on the team recognized that there was no treatment in the jail for Phillip, so the team looked at what other resources would be needed. It was agreed Phillip needed some level of supervision. A commitment to a partial hospitalization program would be obtained. Phillip would go there 5 days a week. In addition, supervised housing was ar- ranged for Phillip. In this way, someone would know where Phillip was or should be at all times. The police and the store manager agreed to call the partial hospitalization pro- gram or the supervised housing unit if Phillip returned to the store. The case manager agreed to work with Phillip and staff in the partial hospitalization unit to seek other goals Phillip might have for himself. The county mental health representative agreed that the crisis intervention team would intervene when necessary if the case manager was off on a weekend or in the evenings. In this way individuals representing a number of different systems or agencies went from feeling frustrated and exasperated to leaving with a plan and some assurance that Phillip would get the assistance he truly needed.

Levels of Case Management

Some agencies have several levels of case management, and clients receive a level of case management commensurate with their need and ability to function. In this text, we look at three levels of case management: administrative, resource coordination, and intensive. In addition, “targeted” or “blended case management” is discussed. In some agencies, these categories may have other names or there may be more than three levels of case management. The following sections provide examples of how case management services might be organized.

Administrative Case Management

This level of case management is assigned to high-functioning individuals who need very little assistance navigating the system. On occasion, they might need a prescrip- tion refilled, an emergency appointment, or a return to outpatient substance abuse treatment, but for the most part they are capable of handling these details them- selves. These people are placed in a pool with other clients who require little service or follow-up beyond the original referral. For the most part, these people function independently, using well the services to which they were referred. When something does come up for a person in this caseload, an available caseworker handles it. This means that an individual on this caseload does not always see the same case manager.

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Chapter 1 Case Management: Definition and Responsibilities 17

Resource Coordination

This next level of case management is reserved for individuals who have some trouble handling the details of their treatment or plan. They usually need help and may have more involved or chronic difficulties that require more assistance. They do not, however, pose a risk to themselves or to others. In addition, with good support, they are unlikely to experience repeated hospitalizations or other crises. Here caseloads are larger, and clients are often in need of services and assistance on issues such as housing, medication, and therapy, but generally the clients do well with the services offered. A person going through a particularly difficult time might be moved up to intensive case management and then return to resource coordination after the stressful circumstances have been addressed.

Intensive Case Management

Individuals receiving intensive case management require considerable supervision, sup- port, and assistance in order to remain in the community and in circumstances that do not exacerbate their problems. Generally, the caseloads of intensive case managers are smaller, allowing for more individual attention. Those in this caseload would be people at high risk for repeated emergencies and hospitalization or at risk of deteriorating to the point that they pose a danger to themselves or others. Intensive case management is usually available 24 hours a day and requires intense involvement to ensure that the person has a support network available and is not in high-risk situations, such as running out of medications or living in a housing situation likely to trigger stress and relapse.

Targeted or Blended Case Management

Some agencies are moving toward a type of case management called targeted or, in some cases, blended case management. This is a different way of delivering case management services. Instead of dividing clients according to their level of need, individuals of varying needs are given to a case manager who carries a smaller casel- oad as a result. In this method, the person has the same case manager through stable times and times of crisis, so that there is good continuity of care and rapport that might support that client when things become unstable.

Margery, a 36-year-old single mother of a daughter, was stable and working when she was transferred to a blended case management caseload. She had needed little contact with the agency in the past year, and the contact she did have was mainly for medication checks and prescription refills. In March, the man she had been dating and talking about marrying was killed in a single-car accident. In the car with him at the time was another woman, who survived the accident and insisted she was actually the man’s girlfriend. Margery was devastated. She began to miss work, jeopardizing her place in the career program she had chosen. She took her medication erratically and gradually became in need of emergency care. Her case manager was a person she had known for some time, and it was her case manager who came at once to the emer- gency room when Margery was brought in by family members.

Liz, her case manager, was shocked at the changes in Margery. Margery was hag- gard, thin, and unkempt. She looked past Liz and said little. Liz made certain there

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18 Section 1 Foundations for Best practice in Case Management

were arrangements for Margery’s daughter with family members and stayed in the emergency room until a bed was found for the patient on the psychiatric unit. During Margery’s 6-day stay, Liz visited several times, worked with Margery to make contact with her work and brought her daughter in for a visit after school one afternoon. When they talked, Liz worked on some of the supports Margery would need to return home. Of paramount importance was that Margery stay on her medication and call Liz when she felt distressed about something.

Gradually, with the 9 weeks of counseling arranged by Liz and a return to work the next month, Liz saw positive changes in Margery. Her home became cleaner and brighter and so did Margery’s appearance, indicating that she was taking an interest in herself and her surroundings. Liz continued to have contact with Margery regarding renewal of prescriptions and regular contact just to see how Margery was doing.

This is an example of blended case management in which one case manager provides services to the same person regardless of the level of need at any particu- lar time. When Margery needed an emergency intervention, she had a case manager at her side with whom she was familiar, someone she knew and trusted. Figure 1.2 illustrates the general case management process.

FIGURE 1.2 Walking through the case management process

To the agency where you are a case manager

Person out here calls in for help

Take initial inquiry on the phone and send veri�cation

letter

Conduct an initial interview

Get signed releases to send for information

Go to Treatment Planning

Conference and develop a service

plan

Write up social history and �ll out the

assessment form for your client population

Provider agency #1

Provider agency #2

Provider agency #3

Make referrals to provider agencies

Monitor client’s services at

provider agencies

Client completes services or moves and you terminate

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Chapter 1 Case Management: Definition and Responsibilities 19

Separating Case Management from therapy

Case management is not therapy. Often beginning case managers believe that they are to do therapy; that is, that they are to provide weekly talking sessions in which deep-seated conflicts and concerns are exposed and resolved. That is not the purpose of case management, and, indeed, most case managers are not prepared to handle this type of work.

In the course of case management with a client, you may uncover deep-seated problems and issues. These become the basis of a piece of the plan developed to resolve these issues. The client is referred to a person or agency that can do that work expertly. As the case manager, you may be the one your clients call when they are hav- ing a crisis and their therapist is unavailable. Good listening skills and helping such people develop a way to handle things until they are seen in therapy is the case man- ager’s role. It is not your role to intervene with a therapy session.

Finally, you will find plenty of other problems that do call for innovative interven- tions on your part. Learning to be independent, adopting useful and appropriate work habits, practicing good interpersonal skills, and behaving appropriately are all areas that you may address with your client in the course of case management. Although the individual may be referred to a specific agency for exactly those skills and that infor- mation, you would then support that intervention in your contacts with the person.

Many clients do not require therapy. Perhaps they have had considerable ther- apy in the past and are not able to benefit from it now or were never able to benefit from it. Perhaps their interpersonal problems are more a result of the chemical imbal- ance they suffer than psychological dynamics. For instance, research shows that indi- viduals who are depressed or suffer from a bipolar disorder do well when they receive both medication and therapy. Many, however, have had considerable therapy in the past and are now maintained on effective medications.

Other individuals may have intellectual disabilities and only need skills to attain as much independence as they are capable of handling. Some people might have suf- fered a crisis such as rape or domestic violence and need a plan that focuses on protec- tion and independence. Others may be out of fuel and need a plan that resolves the problem of a cold home with small children in it. A few clients may have completed a therapy program for substance abuse some time ago and need only an AA or Narcotics Anonymous (NA) meeting and occasional supportive contact with their case manager.

What case managers do is therapeutic in the sense that it benefits the client. Con- ducting clinical therapy, however—where a person comes in about long-standing emo- tional problems or pervasive affective disorders—takes years of study and training and should never be attempted by a person not specifically trained to conduct therapy.

Case Management in Provider Agencies

A provider agency is an agency that “provides” specific services to clients. A case man- ager might refer clients to such an agency for a specific service. There are positions in provider agencies, however, that are sometimes titled “case manager.”

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20 Section 1 Foundations for Best practice in Case Management

Case managers in provider agencies have oversight responsibility for the service or treatment given by the provider agency to the client. These case managers gener- ally make sure the reason for the referral from the general case management unit is actually addressed, and they communicate with the client’s general case manager on progress, goals for the client, and any changes that may need to be made in the service or treatment plan. Because the client is being seen regularly at the provider agency, the provider agency case manager there may also handle some of the per- sonal issues and problems that arise for the client while in the care of this provider agency.

When Jennine came to the Wildwood Case Management Unit, she was suffer- ing from depression and was not able to go to work. After she and the case manager discussed her mood and a social history was developed, Jennine agreed to go to a partial hospitalization program at Marshall River Center where her medications could be monitored, she would be attending groups, and she would get a lunch every day. Her husband agreed to the plan, feeling that this would prevent Jennine from sleeping all day and going without lunch. Jennine, her husband, and the case manager decided on the goal together. That goal was to alleviate Jennine’s depres- sion. They further decided together on the best place for Jennine to go to meet this goal.

At Marshall River, Jennine had a case manager who set up groups and activities to meet the goal. This was important because the Wildwood Case Management Unit generally authorizes payment for the service given to the client and expects that the goals for the client’s recovery will be addressed in return.

The goal for Jennine was to alleviate her depression. Jennine and her gen- eral case manager decided this was a top priority for her. The case manager at the provider agency addressed this goal by instituting a regular lunch and two healthy snack breaks, physical exercise, and group discussions on ways to handle or relieve depression. During that time, the provider agency case manager set appoint- ments so that Jennine saw the psychiatrist once a week for medication checks and adjustments.

During the 4 weeks Jennine was in the care of the Marshall River Center, her husband lost his job. This threw her into a panic and exacerbated her depression. The case manager was in touch with the Wildwood Case Management Unit about these developments. A reassessment was done and there was agreement that Jennine would need 2 more weeks at Marshall River. In this case, the Marshall River case manager saw Jennine daily to talk to her about her husband’s job search and how Jennine was viewing the loss of his job.

In this textbook, you will learn how to do general case management with clients in which you work to address many of the problematic aspects of their lives and make strategic referrals to places where help for them is provided. For example, if Jennine and her husband further stated that part of Jennine’s depression came from her inability to discipline her 8-year-old son, the general case manager might have made a separate referral to parent education classes. Once you understand how general case management is done, you will be able to take on case management responsibilities in agencies that provide services and treatment to clients.

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Chapter 1 Case Management: Definition and Responsibilities 21

Managed Care and Case Management

Managed care is a phrase you will hear often when you go to work. Managed care is a financial system developed to contain the soaring costs of health care. It works like this: A managed care organization (MCO) receives a pool of money, allocated on the basis of a specific number of patients or clients who will be served by this MCO. The MCO hires case managers who oversee the care given in order to prevent the costs of caring for these patients or clients from running over the amount allotted. An MCO can be either a private insurance company or a company that handles pub- lic money.

In situations where the insurance covers medical and physical problems, the case manager is generally a nurse who has specific training in the managed care field. In MCOs set up to deal with behavioral health issues, a variety of social service pro- fessionals may be employed and trained as case managers.

You are most likely to deal with an MCO when working with clients with intel- lectual disabilities, those with substance abuse problems, and individuals who have mental health problems. Because managed care is an economic system to control costs, you may find yourself at odds with the decisions of the MCO case manager. For example, you may be required to receive permission from the MCO case manager before you can implement a service or treatment plan. This is called a preauthoriza- tion. You may have a person sitting in your office who seems clearly suicidal to you, but the MCO case manager is denying hospitalization and suggesting partial hospital- ization instead. There is little room for individual variations or innovative treatment plans in managed care where an MCO is paying for the services because MCOs gen- erally have a cookbook approach to various health problems. There are specific proto- cols or decision trees to help MCO case managers decide what treatment or services are appropriate, and these protocols do not take into account individual differences in clients’ personalities and circumstances.

If you are not an MCO case manager, but rather the case manager seeking pay- ment from the MCO for services you really believe your client needs, it is your role to advocate for your client and the services you feel are the best ones for the current situation. Sometimes you will be able to obtain a better decision for the client and sometimes you won’t be able to do that. However, if you are convinced that what the MCO is proposing is not in your client’s best interest, you owe it to your client to advocate on his behalf.

Figure 1.3 explains some recent trends in case management in managed care organizations.

The Recovery Model

Recovery is a model put forth by the U.S. Department of Health and Human Services and the office of SAMHSA. They are changing the view of mental illness and sub- stance abuse from one of gradual deterioration or a lifetime of chronic illness to one of recovery and a productive life. Spurred by the self-reports of people who have recov- ered from their addictions, mental illness, or emotional problems and went on to live

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22 Section 1 Foundations for Best practice in Case Management

productive lives, this model is being applied to mental health and substance abuse, but it works well in many other fields. Professionals who did research on how indi- viduals recover concluded that it is possible to recover and lead a normal life provided the services are in place that will cause outcomes beneficial to this process.

In this model, case management is extremely important because the research showed that many times people did not recover because they either did not have access to services that would promote their recovery or these services were improperly coordinated. Now the movement is toward services that are diverse enough to meet peoples’ needs, well coordinated, and easily accessible. A person’s hopeful personal vision for his life and respect for that person’s self-determination are always foremost in planning, reclaiming the role of “healthy person” rather than “sick person.” When appropriate, the client’s family is included.

Recovery happens when individuals are able to assume control of their lives, working to establish goals and develop a sense of purpose. When people work on recovery, they are encouraged to take the long-range view, looking toward a future that is more productive, more meaningful, and less stressful to them in ways it has not been before. In addition, people are asked to take a broader view beyond the issues that caused them to seek help, looking at many different aspects of a person’s life. Starting with where the person is at the time, the client is encouraged to think about where she wants to be in a year or in 5 years. How will she get there? What elements does she want in her life? What would she put in her life if she could? What goals would she like to pursue? What issues does she believe need to be cleared up? What

1. Some MCOs want to make the MCO case managers the only case managers for clients. These MCO case managers see the clients directly, make home and site visits, and manage the case as a general case manager might do. In most instances, these case managers are trained social service professionals and would be likely to follow the steps outlined in this book for case management while keeping a strict eye on the financial bottom line.

2. In some places, MCOs are paying for the contact case managers have with their clients. In this way, the agency draws down funds for case management services while providing considerable support to clients. In other words, the more contact given to clients the more the agency is paid and the better service the client receives. This appears to keep individuals in a more stable situation and acts as prevention for crises which are more time consuming and expensive to resolve.

3. Research tells us that individuals with chronic mental illness or substance abuse problems do not live as long as the general population. These people are less likely to seek help, to be able to use the help that is given, and may have had long-term medical issues. Case managers are urged to integrate the physical health needs and the substance abuse or mental health needs of their clients to facilitate a longer and healthier life span.

FIGURE 1.3 Recent trends in managed care case management

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Chapter 1 Case Management: Definition and Responsibilities 23

treatments and services does she want to use? In answering these questions, we intro- duce the elements for positive changes and recovery.

The recovery mission is respectful because it seeks to give clients more self- determination or empowerment and improved role functioning. This is done through a set of identified services combined to result in the stated desired outcomes clients have articulated for themselves, such as improved role functioning, self-development, services that support recovery, and symptom relief. In this model, relapse is seen as similar to relapse in any other illness (for example, diabetes or diverticulitis). Most of the time, the person will be healthy and functioning.

Charles Curie, former administrator of SAMHSA in the U.S. Department of Health and Human Services put it this way: “Recovery must be the common, recog- nized outcome of the services we support.” While SAMHSA developed a list of 10 components of recovery for people with substance abuse problems or mental health diagnoses, these components can support any effort to create plans with our clients For the Recovery Model as put forth by the SAMHSA, see Appendix A.

For Children

At the U.S. Department of Health and Human Services, the Child and Adolescent Service System Program (CASSP) promotes these concepts. They expect case manage- ment to be “child-centered and family focused.” This means that case managers need to have a respectful focus on each child as an individual and need to include the child’s family as a valued partner in planning for the child. The CASSP emphasizes community-based services that keep children at home, or at least in their own com- munity. Further, the CASSP expectation is that case managers will respect and be competent when dealing with diverse cultures.

Also coming from SAMHSA is the resiliency model for children, again based on research. The findings showed that at-risk children often “bounce back” when they have someone in their lives who makes it clear that they are important regardless of the past; with this kind of support, many at-risk children go on to live healthier lives. A child’s case manager certainly should be conveying this important sentiment, but the case manager can also find those people in a child’s life who will do this as well: family members, teachers, youth counselors or workers, or neighbors.

The resiliency model adopts a positive view (the glass is half full) of the child’s life and circumstances, actively seeking strengths on which to build a better future. The belief is that children, like all people, have a “self-righting mechanism” that will help them bounce back from problems using their own power and ideas. The case manager facilitates this self-righting by naming the child’s strengths and teaching the child to acknowledge them. In addition, the case manager either provides or coordinates with others who provide the following: opportunities for the child to participate in meaningful activities, including those that help others; communicating high standards for the child and equally high expectations; providing consistent support and care; increasing prosocial bonding; setting clear behavioral boundaries and consistently

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24 Section 1 Foundations for Best practice in Case Management

observing these; and teaching life skills for success. Combined successfully, these fac- tors allow a child to bounce back successfully.

Further research has shown that the inclusion of several activities not commonly considered when planning formal services is extremely important. A good children’s case manager will develop contacts for these activities. First is reading practice so that at-risk children become competent readers. This is extremely important to later cog- nitive functioning, success in school, and other endeavors. Another activity involves opportunities for children to give something to others, to be helpful, to be in a situa- tion where they exercise concern for others.

Finally, the Resiliency Model seeks case managers who are culturally compe- tent, respectful of diverse religions, and able to respect and include the children’s families.

For Those with Intellectual Disabilities

In the field of intellectual disabilities, the concept is called self-determination or, in some places, it is referred to as Everyday Lives. The emphasis is on clients’ personal choices for the life that is most meaningful to them. Case managers look for services and activi- ties that validate those choices and they collaborate with the family to consider how best to spend money allocated for the care of a person with severe disabilities. Rather than the case manager deciding what the client needs, the family is able to request what would be most helpful to them. Some families might ask to use the money for a ramp and remodeled bathroom to accommodate a wheelchair. Another family might request special speech or physical therapy. What is important is that the case manager takes an active role in helping clients and their families conceive of a hopeful future and looks with them at the supports that could be accessed to make that happen.

Physical Health Is Part of Wellness

Working within a holistic framework involves looking at all areas of a person’s life. In the past, case managers and other providers focused on the immediate problems and on relieving immediate symptoms. Now case managers, particularly, are looking at all aspects of a person’s life. A study by the National Association of State Mental Health Program Directors in 2006 produced some alarming findings. According to the study, “People served by the public mental health system had a higher relative risk of death” NASMHPD, 2006, p. 11. The study went on to report, “Deceased mental health clients had died at much younger ages and lost decades of potential life” p. 11. On average, those with a mental health diagnosis were likely to die 1 to 10 years ear- lier than a person with no mental health diagnosis. While case managers and other service providers were focused on the mental illness, other health issues had been overlooked. In addition, many who needed health care or even needed to receive dis- ability payments were unable to successfully navigate the system.

This study alerted people in the fields of mental health and other social ser- vices to the importance of looking at a person’s health as a whole and to the impor- tance of moving people receiving social services toward wellness on many levels.

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Chapter 1 Case Management: Definition and Responsibilities 25

Practicing case management will mean making sure people on your caseload have regular physical checkups and chronic conditions are being monitored by a health care professional.

For All Clients of Social Service Agencies

In another move in this direction, director Elizabeth J. Clark of the National Association of Social Workers (NASW) testified before the President’s New Freedom Commission on Mental Health in July 2002. She stated that as a profession, the NASW has made a commitment to mental health care that is driven first by the client and the client’s family rather than by the preferences of the professional or the limits of the formal service system. She called for more accessibility to services, early mental health screening, and a national campaign to reduce the stigma of mental illness.

From these efforts, you can see that case management is moving rapidly away from coordination of existing formal services for individuals who are seen as chroni- cally handicapped and therefore unable to lead productive, rewarding lives. Instead, in all fields of service, whether mentioned here or not, the emphasis is on respect for the wishes and the hopeful vision of the person seeking services and then undertak- ing activities that will move that person toward achieving that vision.

For case managers, it now becomes imperative to know what your client wants, not just in terms of services but also in terms of a productive, useful life. It involves careful listening and encouraging people to think about what else might make their lives fuller. It entails respect for the person, their family, and the diversity of hu- man experience. Funding sources are building into their reviews a surveillance of the capacity of case management to support these aspirations not only with standard formal services and, in some cases, medication, but also with the use of community resources and community social supports to assist the individual toward a healthy, productive life.

Caseloads

We have looked at what constitutes good case management. The size of a case man- ager’s caseload can have a considerable impact on how well case management services are provided. Large caseloads can diminish the quality of care and reduce the contacts between the case manager and the client. In such circumstances, case managers are doing little more than reacting to crises. Clients do not have the opportunity to ben- efit from close, stable relationships with their case manager and case managers can come to feel burdened and overwhelmed. There are a number of factors that go into developing the size of a case manager’s caseload. Two of the most obvious relate to financial considerations as to how many case managers the agency can afford to hire and the complexity of the cases the agency handles. Often caseloads are set arbitrarily without evidence that this is the ideal number of cases for case managers in an agency and clearly more work is needed to determine what constitutes an effective caseload for various populations handled by case management.

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26 Section 1 Foundations for Best practice in Case Management

Generic Case Management

The skills you learn to perform here can be used in any social service setting in which clients’ needs and situations are evaluated, addressed, and monitored. Every agency does things in its own way, uses different forms, and often has a specific focus, but the tasks of case management are the same. Once you have learned how take a social his- tory, make a referral, and document contacts, you will be able to take that knowledge to any agency and quickly adapt to that agency’s methods and way of doing things.

Summary

Case management is not therapy, but it requires a set of skills that is nonetheless therapeutic to clients and to their well-being. The practice of case management re- quires an ability to listen to people and accurately assess their problems, offer a range of diverse and innovative interventions, and follow their progress toward the goals they have set for themselves.

New models coming from the federal government and professional organiza- tions stress the importance of giving people ample opportunity to plan for the kind of future they wish to have for themselves. These models have introduced the concept of recovery from the problems and issues that occur throughout the course of life and recovery from substance abuse and mental illness as well. With a belief in the capacity of people to move beyond illness or current difficulties, case managers plan with their clients for more than just immediate treatment and service needs.

In the long run, it is the case manager who takes the long-term view of the indi- vidual. In addition, it is the case manager who develops a comprehensive picture of the person, identifying the specific interventions that each particular client will need.

Think of case management as the foundation. Once you understand the practice of case management, regardless of the career you choose in human services, you will have a deeper understanding of how social services work for people, what social ser- vices can and cannot do, the obstacles people face when seeking help, and the numer- ous ways to circumvent those obstacles. You will be better equipped to work within the social services delivery system or to access it on behalf of your client. Finally, you will have a much broader view of the many interventions and avenues available to help others.

Video Examples

To view the videos that accompany this book, go to CengageBrain.com.

• “The First Interview”—Watch “The First Interview” to see how Keyanna be- gins an assessment with Michelle, a new client.

• “Monitoring: Making a Site Visit”—Keyanna visits with Michelle and her worker at the program where Michelle is receiving services. Here you can see the kinds of concerns that are raised in such a meeting.

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Chapter 1 Case Management: Definition and Responsibilities 27

Exercises

These exercises can also be filled out online at CengageBrain.com.

Exercises I: Case Management

Instructions: In each of the following situations, develop a tentative plan for the client. List the various services you believe each person needs initially. Include in your plan for each client both formal and generic services, and where appropriate, use social supports and support groups. Suggest other services the person might use later once the case is stabilized. Think about how you can involve others close to the per- son and how you will involve the client in planning.

1. You are called by the daughter of an elderly woman who lives alone. The daugh- ter lives in another city and is concerned because her mother does not drive and has seemed unhappy and listless on the phone. The daughter expresses concern that her mother seems lonely and is perhaps depressed. The daughter does not know her mother’s neighbors and calls you instead at the Office of Aging. She has told her mother she is going to call your agency for help, and the mother had no objection to that.

2. A man with an intellectual disability lives alone with his widowed mother. She has fallen and broken her hip and will be at the rehabilitation hospital for about 6 weeks. He cannot stay alone. He has a job at Goodwill Industries. County transportation takes him there every morning at 8:30 a.m. and brings him home at 5:00 p.m.

3. A woman and her two children are waiting to receive their welfare check. They came to your state from another to escape an abusive husband and father. The woman is frail and appears sick. They have no place to go and have not eaten in several days. The children smell as if they need a bath and are listless.

4. A mother of two preteens has brought her son in for services. The woman is a widow. She confides that she has been having trouble controlling the boy, who is the oldest, and that the girl is disgusted with her brother’s behavior and does not want to be involved in helping him. Lately the boy has become involved with teens his age and older. They have been drinking and coming home when they feel like it. The mother allowed them to smoke pot in the garage in hopes that she could keep the boy at home, but now she feels that backfired. The boy

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28 Section 1 Foundations for Best practice in Case Management

makes it clear that he thinks coming for help is ridiculous and says the one thing he will not do is give up his friends.

5. A man has been referred by his family physician for help. The man seems ex- tremely inebriated. His wife brings him in and says she is worried that he may go into delirium tremens if he withdraws from alcohol too quickly. His family physician did not see him but sent the couple straight to your office.

6. A father brings in his 14-year-old daughter who is running the streets, refusing to listen, and failing in school. He is at his wits’ end, saying he must work and cannot be home when the girl returns from school. Her mother died 4 years ago, and the trouble started when the daughter was about 12. The father feels that he and his daughter have a difficult time communicating with one another.

7. A police officer asks you to come to the home of an older man he has been con- cerned about for several weeks now. The man is delighted to see you and tells you that he is having pains in his legs and is unable to walk. During your visit, he asks you to get things for him that are nearby, but obviously it is too painful for him to get up. He says he does not go to the kitchen often to prepare meals, but the police officer has stopped by several times with sandwiches, and Mrs. Jones from up the street, an old friend of the man’s late wife, has brought a casserole on occasion. He is adamant that he wants to stay in his home as long as he can.

8. A woman comes in complaining of depression. She says it started when her hus- band left with a younger woman and she has not been “right since.” She reports having difficulty falling asleep and complains of no appetite. She says she has missed more than 3 weeks of work since he left last month. There are no chil- dren, but she tells you she has neglected the dog and cannot remember if she fed him last night or not. She appears listless and very sad, weeping off and on during the interview.

9. A man in his 60s comes in on the recommendation of his doctor. He had a back injury some years ago and was placed on codeine at the time. After the back in- jury, other things went wrong. The plant where he worked closed down and his

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Chapter 1 Case Management: Definition and Responsibilities 29

mother died. He found himself feeling very alone and uncertain about finances. “It was then that I started to drink too,” he tells you. When you ask what he means by “too,” he says his doctor believes he has become addicted to codeine. “I don’t know,” he says. “I’ve gotten to the point that I can’t get through a day without a lot of help.”

10. A single mother brings her 12-year-old son in because they are “not getting along.” She reports that he does not listen and comes and goes as he pleases. His homework has fallen off and his grades have slipped, but he is still doing well in math and likes his math teacher. The boy’s father was killed in a railroad accident 2 years ago. The mother tells you that the boy and his father enjoyed a close and warm relationship, and that she has felt her influence on him slipping away since the accident.

11. A woman comes to your agency on a referral by the courts after she was arrested for selling various prescription medications on the street. She tells you she cur- rently has some amphetamines, Xanax, and a popular addictive pain medication in her bag. The court is ordering her to show within the next week that she has enrolled in a program that will get her help with her own addiction to some of the medications she sells. “I have regular customers,” she tells you. “And they are going to crap when I stop coming around.” Asked where she gets her medica- tions, she smiles mysteriously and says, “The police are looking into that—you don’t need to.” She denies she is addicted to anything, but court records, includ- ing an evaluation by a psychologist, which she has brought with her, indicate that she is addicted to several different medications.

12. A woman who was recently placed in the community after 3 years in a state mental hospital is having trouble adjusting to the living arrangement made for her by the hospital. She is not going out and does not participate in any activi- ties. She is friendly when you talk to her and seems glad to have your company, but she does not seem to know how to take care of the details of everyday liv- ing. She has a roommate who is more competent and independent. The two get along well.

13. A woman with two small children is referred to you because she recently lost her apartment. She has a meager income from a part-time job as a clerk in a

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30 Section 1 Foundations for Best practice in Case Management

convenience store and was unable to pay the rent and take care of other bills. She seems unaware that she might be eligible for financial assistance. She is not sure where her children’s father is at the moment. All her belongings are packed in five bulging garbage bags. She and her children seem malnourished and thin.

14. A man comes in who was referred by his job for possible crack use. The man admits he uses crack, but rarely and certainly not to the extent that it would interfere with his work. He will be given 4 weeks off if he enrolls in a legitimate program for detoxification. He seems reluctant and torn. Eventually, he agrees to work with you on a plan.

15. An older woman comes to you for help after a particularly abusive incident with her husband. She admits that she is becoming increasingly afraid of him. She has no friends and no job, “because he wouldn’t let me out of the house—or out of his sight.” She has a number of old bruises and lost two teeth in this last inci- dent. She is asking for help and says, “I don’t know. I really fear for my life. It’s just gotten out of hand and I don’t know where it will end.”

Exercises II: Decide on the Best Course of Action

Instructions: Sit with a small group of other students and decide how you will han- dle each situation. There are many areas both ethically and legally that are not clear, so the discussion you have with your colleagues about these cases is much like a dis- cussion you might have in a real agency. There are no “correct answers.”

1. You are the case manager for a man who has only recently had a first manic episode. He had submitted to treatment, responded well, and returned to work. However, he is currently experiencing another episode, and this one seems more severe. He is not sleeping or eating, is sending cryptic messages on the Internet, and believes everything he reads there is directed at him. He believes the gov- ernment is “monitoring” him, and that he has an important job lined up with a record company in New York. You have determined that he is not leaving his house, and that he is preoccupied with what is happening on message boards and chat rooms on the Internet. You have checked in with him several times by phone. Each time he assures you that he is fine and does not need help.

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Chapter 1 Case Management: Definition and Responsibilities 31

What is the best course of action? Do you risk seeking an involuntary commit- ment, knowing that he seems just well enough to convince the emergency room physician he is not in need of hospitalization? Will this alienate him and make it impossible for you to work with him? Do you wait for things to get worse? If so, is there a chance he may leave the house and get into trouble? What might hap- pen if you wait it out?

2. A 72-year-old woman on your caseload has been in mental health services for a number of years, ever since the year after she graduated from college. She has had severe episodes of schizophrenia over the years with countless hospitaliza- tions and prescriptions for numerous antipsychotics and antidepressants. All her life she has been a client of social services and hotlines, reaching out frequently for any support she could get. She has always been very dependent on her case managers, calling them often for support. When support was withdrawn, as it often was when workers tried to get her to be more independent, the woman would deteriorate.

Sometime after she turned 60, these severe, acute episodes diminished, and she has been living in comfortable subsidized living arrangements for senior citizens. As she has grown older she has developed breathing problems that will eventu- ally take her life. In an effort to be helpful and without your knowledge, her family doctor referred her to hospice for support. In his view she was facing the end of her life. Hospice entered the picture with considerable support, seeing her often, providing meals and companionship. This level of attention met the woman’s needs for support and she became extremely dependent on the hos- pice workers. She seemed happier and began to participate more in the group activities at the apartment building where she lived. This level of support is more than you could give and you have been relieved that she is doing so well with the hospice workers. However, hospice has decided to withdraw their services. The woman’s death does not appear to be imminent. In fact she appears to be improving slightly. The woman has called you, her case manager, in a complete panic at the prospect of losing this support. She is not eating and is distraught.

What are the ramifications here? What does continued hospice support mean for hospice, which relies on public and charitable funding? What are the con- sequences if the services are withdrawn for this woman and for you? Are there solutions to this problem? Are there ethical considerations here?

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Chapter 2 Ethics and Other Professional Responsibilities 33

Ethics and Other Professional Responsibilities for Human Service Workers

Introduction

Ethical principles are the foundation of good human service practice. In fact, workers who do not practice within ethical parameters cannot be called professional. True professionals understand their ethical obligations and seek guidance when they do not. Each social welfare profession, from psychologists to social workers to human service workers, develops a set of ethical principles appropriate to the practice. Most professions monitor the behavior of their members with regard to these principles, singling out those who violate ethics codes for disciplinary measures.

Ethical principles are generally created in order to protect and prevent the exploitation of the individuals who come to us for service. In the work we do, there is considerable opportunity to exploit vulnerable people because the people who seek our help are dependent upon us for the aid they need. Any violation of their trust on our part will only compound the person’s problems. Ethical principles provide guide- lines to protect individuals from exploitation. However, when professionals practice within the parameters of ethical principles, the public can feel confident that their interests will be respected and protected. Thus, ethical principles inform the decisions we make that affect clients, and they provide guidance in choosing the approaches we take with clients.

In this chapter, we will look at some ethical guidelines common to all the helping professions. Failure to know and follow these guidelines in your future practice can result in dismissal from an agency or, worse yet, in a civil suit brought against you for a violation of the ethical code wherein the violation caused damage to the person.

C h a P t E R 2

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34 Section 1 Foundations for Best Practice in Case Management

If you have earned a license to practice in the human services you can potentially lose your license. Although violations of ethical principles may have negative conse- quences for you and your career, they are always extremely destructive for the indi- vidual, who is already vulnerable.

The Broader Ethical Concept

Ethical behavior can be viewed from three different aspects: moral, ethical, and legal. We examine these three aspects below.

1. Moral. Moral choices have to do with culture and socialization. We choose what we believe is moral behavior based on what we feel is right, what we have been socialized to view as morally correct, and what the culture in which we grew up would view as morally right. Often, morality is tied to the religion we practice. We internalize certain moral principles and choose to apply these principles as we believe they should be applied. Usually, when we violate what we feel is moral behavior we wrestle with our own guilt, but we usually do not face public condemnation or punitive action unless the behavior is also illegal or violates an ethical code.

2. Ethical. Ethical behavior is usually represented in ethical codes. These codes are generally developed as guidelines stipulating the behavior of members in particular groups or professions. They are not applied at the discretion of the individual but are required to maintain professional status. Violations of these codes will often result in sanctions applied by the group or profession against the individual. Suspensions and loss of privileges often follow violations of ethical codes.

3. Legal. When we refer to what is legal we are referring to what is the law. Laws will often embody moral and ethical principles, but not always. Governments and the courts determine what is legal and illegal behavior, what behavior is a criminal offense. The courts make decisions about the consequences for illegal behavior.

In all three of these concepts there is certainly overlap. For example, it may be illegal to have sex with your client. Prohibitions against this behavior will almost certainly be embodied in your ethical code as well and clearly sexual encounters with clients would be viewed as immoral behavior by professionals.

However, because some practitioners apparently did not see sex with clients as immoral, professional groups saw fit to place sanctions against such behavior in ethical codes for social service professions and eventually states enacted laws prohibiting this type of behavior and making it a crime.

We can look at a case involving a principal at a school in Colorado. She objected to the fact that children who could not pay for their school lunches had their hands stamped, embarrassing some children to the point that they skipped lunch. Clearly, she found this humiliating to children and therefore an immoral practice. However, there is no legal basis for stopping this and it would take some time to find and apply

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Chapter 2 Ethics and Other Professional Responsibilities 35

an ethical prohibition against such behavior. Sometimes we find that what we believe to be moral behavior is included in ethical codes or in the law. Sometimes it is not. We may find that ethical codes involve behaviors we never considered particularly immoral, and laws may or may not coincide with ethical codes or common beliefs about morality.

Our personal responsibility is to respect and follow the ethical codes that apply to our profession and the laws that govern our work. In addition, we have an ethical obligation to know and be aware when we practice what we believe to be moral behavior with regard to our relationship with clients. Many of the situ- ations we encounter that require us to choose the right action are gray areas that call for discussions with supervisors, a rereading of our ethical codes, and some- times consultation with a lawyer to better understand the law. Codes, whether they are legal, ethical, or our personal morality, are guidelines to help us construct the best response in difficult circumstances. You will, however, encounter circumstances that are not explicitly covered anywhere and these will require you to thoughtfully construct the best legal and ethical decisions based on careful consideration and consultation with others.

AssIgnmEnT

Find the ethical code for the profession you are interested in pursuing. If you want to become a social worker, look for the code of ethics for social workers. If you are in- terested in becoming a psychologist, find the code of ethics for psychologists. There are codes of ethics for human service workers, for therapists, family therapists, and group therapists. Read the code of ethics that applies to your chosen profession and be able to discuss it in class.

Dual Relationships

A dual relationship occurs when you and a person to whom you are giving services have more than one relationship. You may be this person’s case manager as well as her cousin, her boyfriend, or her customer at her beauty salon. Or you may be a person’s case manager and also his employer for your yard work, his Sunday school teacher, or his Little League coach. In other words, a dual relationship occurs when you are in two different relationships with a person, one related to your position as the person’s case manager and the other unrelated to that role.

The first rule is to avoid all dual relationships. Your practice gives you a position of power. People tend to look up to you as someone who can provide real assistance. Furthermore, you might be the one who will determine when a person can return to work, or you may be the person who reports an individual’s attendance in your program—attendance that keeps that person out of jail. It is possible that you could exploit or give the appearance of exploiting this power. In addition, there is enormous potential for a conflict of interest.

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36 Section 1 Foundations for Best Practice in Case Management

Suppose, for example, that your supervisor tells you on Thursday afternoon that you have been chosen to represent the agency at a big dinner being given to honor a county official at the Hilton Hotel on Saturday night. This gives you little time to prepare. You need to get your hair cut and styled. You call a man who receives services from you who is a hair stylist, and prevail on him to work you in at the last moment. He does you a favor and sees that you get a good appointment. You are very grateful, go to the wonderful dinner, and think little more about it.

Several months later this man calls you. He has a need for a prescription refill from his psychiatrist. It is Friday afternoon, and the psychiatrist will not be back in the agency until the following Wednesday. He feels you should be able to do this favor for him because of the favor he performed for you. He does not have time to see the psychiatrist regularly, he tells you. When you refuse to call in a prescription for him without the doctor’s prior knowledge, he cannot understand why you are being “so rigid.” He indicates that he thought the two of you were friends who helped each other out when needed.

Whatever you do in this situation, you will lose. If you call in the prescription, you will have violated an agency rule that a person must be seen at regular inter- vals by his psychiatrist before medications can be refilled. This could cost you your position or result in a disciplinary action. On top of that, you could start down a very slippery slope with this individual. He may come to expect special favors from you and offer you special, very tempting favors related to his business in return. On the other hand, if you do not call in the prescription, you have alienated someone who needs the services of your agency. You have created a barrier to his feeling comfort- able with you and getting the help he needs in the future. The individual is harmed. A relationship that was or could have been useful to him in resolving problems is now something else. The opportunity for real progress is diluted with issues of friendship and favoritism.

From a shortsighted point of view, you and this person may see the convenience of exchanging favors as trivial and unrelated to the therapeutic relationship. In the long run, however, when scenarios such as the one just described occur, the rela- tionship can never return to a professional one; and if in the future this individual is in acute need, you may no longer be able to provide the professional intervention needed.

When working in the field of substance abuse, opportunities for dual relationships are many and require special vigilance. For many practitioners, addiction is a firsthand experience and helping others cope comes from deep personal trials and challenges. The field of substance abuse emphasizes peer support and diminishes hierarchical patient-therapist relationships. Nevertheless, friendships and therapeutic relation- ships are not the same thing, and it is not helpful if people come to think of the two as similar.

Perhaps you are still attending AA meetings and your clients are also attending those meetings with you. Issues about how much to reveal to others and to what extent we socialize with clients who are also friends from AA are challenges that must be faced. Lester worked in a halfway house and attended AA every Tuesday evening. Two of his residents went with him. Lester felt that revealing a lot of his past in these

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Chapter 2 Ethics and Other Professional Responsibilities 37

meetings undermined his relationship with his clients. For one thing they often asked for more information about things he had revealed in AA when he saw them privately, seeking a level of detail Lester did not feel comfortable discussing with them.

Socializing as friends with people who share your AA meetings can be tricky if you are also the person’s counselor. Lester tried to avoid friendships with the members of his AA group because they knew where he worked and often asked him for advice or interventions on their behalf based on the assumption that “we are all friends.” One client asked Lester to be his sponsor, pointing out that Lester was in such close proximity that it would be easier for them to communicate. Lester suggested the person find another sponsor, but it seemed to leave a bad feeling between them. It is wise to be aware of the issues Lester faced in his work and know how you will address these.

In some very small, rural communities, it is not possible to avoid dual relationships entirely. In those situations, after doing all that you can to make other arrangements, you must talk with the person about the possible problems that could arise and how each of you must avoid these problems together. Then the person has the choice to continue the relationship, find other arrangements, or discontinue services altogether.

Gifts from People You Serve

Although gift giving by those whom you serve does not pose a dual relationship, people who bring gifts for you do pose a particular conflict of interest. It is usually best to avoid accepting gifts to keep the relationship professional. Often, though not always, gifts are the person’s way of manipulating the situation. “I’ll give you this item and you accept it. Next time you owe me something,” or “I gave you this lovely thing. I am such a nice person. Even you think so or you would not have taken my gift. How can you then refuse to give me what I want?” People need to learn to express their desires clearly rather than by using gifts.

Gifts are not always manipulative, however. For example, a case manager working in a fuel assistance program worked closely with a family. The husband was injured when an automobile he was working on at a garage slipped on the lift. Unable to work, the family’s meager resources began to dry up. The wife managed to find work in a greenhouse, but as winter approached, she was laid off and the expenses, particularly for fuel, increased. The couple had two children, both in elementary school, and they struggled to clothe and feed them as the wife sought another job.

The case manager saw this family through their difficulties by getting them welfare checks, seeing that the husband enrolled in the community college for courses in high-tech auto repair while his injuries healed, and finding school clothes for the children. The husband did well in school that winter and set a good example for his children, who seemed to do better in school than they had the previous year. The wife returned to the greenhouse in the spring and found that not only was she needed as a manager, but there was also a strong possibility she would have a year- round position there.

Elated by how well things were going and how much better the future looked, the couple came to see the case manager one day in the early summer and brought

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38 Section 1 Foundations for Best Practice in Case Management

her a pot of black-eyed Susans from the greenhouse. “We just wanted you to have these for all you have done for our family,” the husband said, smiling expansively. The husband and wife looked pleased and happy. Obviously, the couple was proud to now be in the position to be able to give something too. It was important to them not to see themselves as the recipients of handouts all the time, but to be able to also give something to someone who had been helpful to them.

Refusing a gift in such circumstances can be interpreted as rejection. If the worker had said, “Oh, I can’t accept that. You’ll have to give it to someone else,” a person might have heard a different message: “You are the client and I am the benevolent worker. I help you, but you can never get to the position where you could possibly do anything for me. I don’t need anything you could give me; but you, on the other hand, are a poor soul in need of my help.”

If your agency has a policy against your personally accepting gifts, try to find a way to accept a gift of this sort on behalf of the agency. In this case, the worker planted the flowers in a planter near the door of the agency. This was a better solution than outright rejection of the gift.

The rule is to be very careful about accepting gifts from people you serve. Whenever an individual offers a gift, make a note in the person’s record of the offer as well as whether the gift was accepted or rejected and why.

Sexual or Romantic Relationships

Individuals who come to human service workers for help often feel isolated, discouraged, and misunderstood. The relationship they form with a respectful, concerned worker may make them feel understood and appreciated for the first time. This relationship may be so comforting that people attempt to turn it into something more permanent, more personally meaningful.

It is not uncommon for people to fall in love with their workers in what we call “transference.” In a sense, such individuals transfer to the workers the attributes they are seeking in another person. They may assume the love and affection they are seeking will be forthcoming from their workers because the workers have been so kind and helpful. These people fall in love with their workers because of an erroneous perception: They see concern and encouragement as gestures of love and affection— as an invitation to create more than a professional relationship.

Countertransference also can occur. It is not unusual for workers who are harried and overworked, and possibly coping with difficulties in their personal lives, to find the willing ear of a person to whom we give services very supportive. The people we serve are often attractive, sensitive people who can convey warmth and support when case managers are most vulnerable.

Take, for example, Kent, a case manager. Kent’s wife left in the middle of a Tuesday morning, and Kent was to be at work that afternoon at 3:00. Though he fought hard to dissuade her from going, she left. For the rest of the day before work, Kent tried to get some money from their joint account, tried to find out where his wife was going, and tried to make some decisions. He arrived at work feeling exhausted and bitterly betrayed.

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Chapter 2 Ethics and Other Professional Responsibilities 39

That evening, Kent made a home visit to Lucy’s house. Lucy had first come to the agency with extreme depression, but she was doing so well now that Kent was considering terminating these follow-up visits. Lucy, an artist, greeted Kent warmly. She had put on a pot of tea and made some banana bread for his visit. Gratefully, Kent sank down on her sofa. Instead of asking Lucy how things were going for her, whether she had enough medication, and whether she had any medication questions, Kent found himself talking about his upsetting day.

In response to Lucy’s first remark, “You don’t look very well tonight, Mr. Paulman,” Kent heard himself pour out the day’s events; then he went on to talk at length about how his marriage had unraveled. He felt comforted by Lucy’s interest in him as she lis- tened intently. Here was a person who appeared to respect him as a professional and as a person. Here was a woman willing to listen to his problems. Here was a warm retreat from the job and the problems of the day where Kent could feel safe and supported.

Kent never intended for a real relationship to develop between Lucy and himself. In fact, as he left that night, he told himself that he might have crossed a dangerous line and that he should avoid further contact of this sort with Lucy. Nevertheless, based on that evening, Lucy called; and because Kent was lonely, his life was uncer- tain, and he was filled with anger and bitterness about his situation, he continued to see Lucy, finding in her a warm, supportive person, someone who could reassure him by her presence that he was attractive and interesting.

The relationship moved from his visiting in her home after work to his staying overnight at her house to his moving in his belongings and beginning to live there. They went out on dates. The furtiveness of these activities only made the relationship seem more romantic and important. Finally, a supervisor discovered the relationship, and Kent lost his job. After 3 years, he and Lucy have separated, and Kent is not working in the human service field anymore because he violated such an essential ethic. Instead, he sells appliances in a local store. Lucy became depressed when the relationship ended and has entered treatment again.

The person responsible for maintaining a professional relationship regardless of personal feelings is the case manager. Regardless of how you feel about the person on your caseload or how that person apparently feels about you, you are the responsible party. You will be penalized if the relationship crosses from professional to intimate. It is always assumed that the individual you are serving is the vulnerable party.

Figure 2.1 lists some warning signs that indicate when a worker or an individual receiving services might be moving away from a professional relationship and toward a personal one. Make certain you are familiar with these signs.

PlEAsE noTE!

It is a violation of all ethical codes, and in most states against the law, to engage in a sexual or romantic relationship with a person receiving services from you. This is clearly exploitation. It is never tolerated. You must be aware that, although attractions can occur between those receiving service and those who provide service, acting on those attractions is entirely unethical and generally illegal in professional practice.

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40 Section 1 Foundations for Best Practice in Case Management

Boundaries

Kent’s situation with Lucy demonstrates a problem with boundaries. Karst-Ashman and Hull (2006, p. 402) define boundaries in the human services as “invisible barriers that separate various roles and limit the type of interaction expected and considered ethically appropriate for each role.” Many ethical problems arise for social service workers when they have a vague understanding of boundaries or they cross those boundaries. It is the worker and not the client who is responsible for being aware of where the boundaries lie. Clients may attempt to cross boundaries but the worker is the one responsible for making sure that these lines are observed.

Let’s look at examples where boundaries are crossed. Obviously, Kent’s relationship with Lucy crossed a boundary, but there are many less obvious ways to violate boundaries. Perhaps you have had a similar problem and want to get feed- back from the group you are leading about your problem. Maybe you want your daughter to play with the client’s daughter and the two of you become friends. Perhaps you listen to a problem your client is having and because you know the people who caused her difficulties you stop speaking to these people and let others know that they have been the cause of your client’s problems. In another instance, you might lend something personal to a client, have a client stop by the house on occasion, or find a client so much like yourself that you make him a friend and see him in social settings as well. There are countless, often seemingly harmless ways, that you can turn a professional relationship into a friendship or an exploitive relationship.

A good part of understanding your ethical obligations is knowing where the professional boundaries are for the population with which you work. Some popula- tions have a closer relationship with their workers than others. In women’s programs and in some substance abuse programs, sharing common problems is not unusual. In programs for individuals with developmental disabilities, socializing with the clients of the program is not always frowned upon. Enter your work aware of the fact that there are boundaries that govern your behavior toward clients and become familiar with these.

Value Conflicts

Generally, the person’s values and your values have little to do with why the individual is seeking services from you. Sometimes, however, religious, moral, and political values play a pivotal role in the problems people bring to agencies. It is rare for case managers to get deeply involved in such primary problems, but it can happen.

First, you can be prepared by consciously knowing yourself and your feelings about certain value-laden issues. Then, if a conflict of values occurs between you and an individual you are serving, you should be able to tell that person that the conflict exists and may interfere with services. You can begin to inventory some of your own attitudes and strong feelings by completing the self-assessment exercise in Figure 2.2.

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Chapter 2 Ethics and Other Professional Responsibilities 41

FIguRE 2.1 Warning signs that the worker–client relationship may become too personal

Warning signs from the Client

• The client shows overt sexual interest in the worker either through conduct or verbally.

• The client describes dreams that are increasingly sexual in which the worker is prominently involved.

• The client is excessively interested in the worker’s private life. • The client inquires about the worker’s relationship with his or her spouse and

children. • The client attempts to give the worker romantic gifts. (Be careful about accepting

gifts from a client. Note every such offer in the record, along with whether the gift was accepted or rejected and why.)

• The client wants to see the worker outside the office in places such as restaurants or movie theaters.

• The client gives the worker romantic poetry or brings in romantic articles and books.

• The client dresses in seductive attire. • The client interprets the worker’s statements of concern for the client to mean the

worker has a romantic interest in the client. • The client repeatedly hugs and touches the worker. • The client indicates a desire to be special to the worker.

Warning signs from the Worker

• The client is prominent in the worker’s dreams. • The worker looks forward to seeing the client, more so than other clients. • The worker begins to see the client as more understanding than others in the

worker’s life. • The worker inquires about the client’s sexual life and fantasies when these are not

relevant to case management. • The worker is more interested in this client’s attire than in the attire of other

clients. • The worker is more concerned with his own attire on days when he will see the

client. • The worker begins to see the client as a person without issues or problems or

minimizes these so that the client seems more acceptable as a partner or friend. • The worker takes many innocuous actions the client might interpret to mean the

worker has a special interest in him or her.

Source: Based on a list created by attorney O. Brandt Caudill (1996). Used with permission.

Second, if a severe conflict of values exists, you might need to make arrangements to transfer the person to another case manager. You would not do this because of a simple value conflict, but you should try to make such a transfer if you find you can no longer be objective, you are extremely uncomfortable with the person because of her or his values, or you feel compelled to counteract the individual’s values by imposing your own.

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42 Section 1 Foundations for Best Practice in Case Management

self-Assessment Exercise: Possible Values Conflicts When Helping others

Look at each description of a person or group of people, and assign a number to each.

1. Give the description a 1 if you think you could work with the person or group. 2. Give the description a 2 if you think you could work with the person or group, but

would find it uncomfortable or difficult. 3. Give the description a 3 if you could not work with the person at all.

_____ 1. A woman who wants you to help her feel comfortable with her decision to have an abortion

_____ 2. A man who frequently brings up his fundamentalist religious beliefs _____ 3. A homosexual couple who want help in improving their relationship and

resolving their interpersonal conflicts _____ 4. An interracial couple seeking premarital counseling _____ 5. A man from Iran who strongly opposes the equality of women and talks

about women working in denigrating tones _____ 6. A man who has for years been getting more welfare than he is entitled to

receive by using certain tricks he developed to beat the system _____ 7. A man and woman who say they want to improve their marriage, but the

man will not end his affair with a second woman _____ 8. A white couple seeking help for behavior problems with their adopted

son, who is African American _____ 9. A man who makes it clear he often disciplines his children by using

corporal punishment _____ 10. A person who refuses to discuss feelings and says that all that matters are

facts and logic _____ 11. A woman who has chosen prostitution as a way to support herself and her

children _____ 12. A gay man dying of AIDS who comes in with his lover to resolve conflicts

around how he contracted the disease _____ 13. A man seeking help to curb his extreme abuse of his wife _____ 14. A woman who sexually molested her son _____ 15. A lesbian couple seeking to adopt a child _____ 16. A woman dying of breast cancer who wants to take her own life _____ 17. A person who relies heavily on cocaine to get through the day _____ 18. A couple who are openly anti-Semitic _____ 19. A vocal member of the Ku Klux Klan _____ 20. An orthodox Muslim who cannot always see you because his

appointments often interfere with his times of prayer

FIguRE 2.2 Self-assessment exercise

Digital Download Download from CengageBrain.com

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For example, a human service worker who did not personally believe in birth control (including tubal ligation) was a case manager for individuals with developmental disabilities. When a young couple on her caseload decided to marry, she became actively involved in discouraging them from the idea, particularly when she learned that the woman planned to have a tubal ligation so that they would not have children. The families of the two individuals supported the marriage.

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Chapter 2 Ethics and Other Professional Responsibilities 43

The  people were high functioning, each one had a job, and each had the support of other community agencies.

In the months before the wedding, the case manager did not attempt to transfer the cases to another case manager. Instead, she harangued the couple about the sins of birth control and of marriage without children, and about the unwise decision to marry at all, given their “mental impairment.” The families complained to the agency, asking that she stop pressuring these vulnerable individuals. Twice the supervisor disciplined the worker. When the worker persisted—visiting the couple’s minister who would perform the ceremony, the supervisor where the man worked, and the woman’s parents—she was fired from her position.

The worker’s behavior was harmful to this couple. For those two people, who had always relied on a case manager who had seemed to be wise, the worker intro- duced uncertainty and fear. Her constant negative warnings damaged their fragile self-confidence and self-esteem. For them, what should have been a happy deci- sion, supported by family and friends, became a decision fraught with anxiety. Fam- ily and friends had to work long and hard to restore their confidence in their original decision.

This is an example of the worst possible way to handle a values conflict. In this situation, the worker attempted to impose her own point of view, her own personal values, on the couple. She denied them the right to choose for themselves and interfered in what was largely a personal and family issue unrelated to case management.

Avoiding Value Conflicts

Following are some rules for avoiding value conflicts and ensuring that individuals get professional service from you:

1. Be respectful of attitudes and lifestyles that differ from your own. 2. Never practice prejudice toward minorities, those with disabilities, or those

differing in sexual preference. 3. Always give your best service to a person, even when you disagree with the

person. 4. Never attempt to change the individual’s values to coincide with your own.

Using Values to Motivate People

When people come in seeking assistance, they are usually hoping to make things better in their lives than the way they are right now. In the course of your time with them, it is important to explore the values that caused them to seek help. Find out what goals people have for themselves if their situations were better, and what values those goals reflect. Here we are looking at the things that people value for themselves: being a good parent, living an independent life, living free of the symptoms of schizophrenia, or being free of cocaine addiction. The person is envisioning some- thing up ahead that involves a goal or value dear to that person.

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44 Section 1 Foundations for Best Practice in Case Management

You often learn about people’s values when you ask them where they would like to be in 5 years. What you hear when they answer will point to what they hold important for themselves and those around them. When people are having trouble making changes that will move them toward their personal goals and visions, it is helpful for the worker to know what the individual’s values are and to look at the person’s situation with those values on the table.

The Rights of Individuals Receiving services

Anyone who gives service in one of the helping professions must be familiar with the rights of the person and make a particular effort to see that people understand they have rights when they seek help. Often people mistakenly assume that they have few or no rights when they come in for services. In addition, professionals may fail to inform individuals of their rights because it is easier to work with people who are vulnerable, dependent, and uninformed. This, of course, sets up a situation in which it is easy to exploit the person. The purpose of educating people about their rights is to allow them the opportunity to become active participants in their care and partners in decisions that affect them.

Most agencies prepare clients’ rights handbooks for those receiving services to keep as a reference. A hospital for the mentally ill would include the right to be released from the hospital as soon as care and treatment in that setting are no longer required. Nearly all agencies inform people that they have the right to participate in the development and review of their treatment plan. People generally have the right to participate in major decisions affecting their care and treatment. Most of those who are involuntarily committed to an inpatient setting have the right to refuse treat- ment to the extent permitted by laws in that state or the right not to be transferred to another facility without clear explanations regarding the need for the transfer. Inpatient units stipulate it is the person’s right not to be subjected to harsh or unusual treatment. The hospital may also spell out the fact that the individual may keep and use personal possessions, or the person must be informed about why something is being removed. In most settings, people have the right to handle personal affairs and to practice the religion of their choice.

In outpatient settings, people have the right to a flexible and responsive treatment plan, the right to expect an individualized plan of service, and the right to make suggestions and express concerns. Often there is a procedure individuals can follow if they are dissatisfied with the worker assigned to them or the service plan laid out by the agency.

The following sections discuss some important rights that belong to those receiving services.

The Right to Participate in Planning

When you sit down with someone to begin planning what services would work best or what treatment would be most effective, you each bring unique perspectives to

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Chapter 2 Ethics and Other Professional Responsibilities 45

the table. You have a detailed understanding of what is available, which services work better than others, and where people on your caseload can receive treatment or service tailored to them. A person comes to the table with information about them- selves that is useful when planning. Putting these two pieces of information together makes for a more effective plan. People who work with you feel that they have had a part in the planning and therefore, some control over the direction of their care. This makes it more likely that the plan will be followed or that individuals will tell you if they see the need for a change.

It is for this reason that we do not just disrespectfully tell people what their service or treatment plan will be without consulting them first.

The Right to Self-Determination

Educating people and informing them about their rights are both done so that cli- ents can exercise the right to self-determination. Paramount to any relationship be- tween professionals and their clientele is the right to self-determination. People have the right to do research about their diagnosis or problem and to question the treatment plan or make suggestions. People have the right to withdraw from treat- ments and services they find are not helpful. People have the right to decide when and for how long they will use services (unless their involvement with the agency is based on an involuntary court commitment). People have the right to choose their own goals.

Often this presents a problem for a worker who feels compelled to look after the best interests of the individual. One of the hardest lessons you will ever learn is how to let people make mistakes and learn from those mistakes. You can make sug- gestions and express concerns, but ultimately clients have the right to determine what they will do. You may feel strongly, for example, that one individual is not ready to walk away from the agency; and you may feel certain that the person’s do- ing so prematurely will result in further problems with alcohol. In fact, your client leaves treatment against your advice and eventually does end up with another DUI charge. Although your worst fears and predictions came true, you cannot know for sure that the work with you and the new charge were not important learning oppor- tunities. In other words, people have the right to test the waters, so to speak, and to learn that they are not as ready as they thought they were. In fact, one of the ethical considerations for workers in the field of addictions is to be willing to view crises as opportunities for change and growth. It is useful to consider crises in other fields in this light as well.

Increasingly, however, self-determination means more than this. More and more funding sources and governments, as we saw in Chapter 1, are asking case managers to go beyond simply arranging for services in collaboration with the client. They are asking case managers to encourage people to articulate what their vision of a healthy, productive future would look like. As people do better on medications and remain in their communities, how they function in those communities—how they contribute, feel secure, and pursue their own interests—becomes more impor- tant. Self- determination now takes on the future beyond the social and emotional

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46 Section 1 Foundations for Best Practice in Case Management

problems that were the original reason for seeking help. Now people are being en- ergized by their case managers to explore and create a better tomorrow of their own making.

Informed Consent

A person receiving services always has the right to consent to these services or withdraw from them. In making this decision, the person must be informed enough to make a wise decision. When the individual is informed and consents to treatment, we call that informed consent. Making certain that a person can give informed consent begins with the intake, during which the agency policies are explained and choices of treatment or services are outlined. This level of information should continue through- out the entire relationship between the individual and the agency until termination. This means that people informed about treatment or services can make their own decisions with regard to the services.

The following list contains items that should be addressed when relevant to the person’s services. The person has the right to be informed about:

1. Any side effects, adverse effects, or negative consequences that could occur as a result of treatment, medications, or procedures

2. Any risks that might occur if the person elects not to follow through with treatment or services

3. What is being offered to the individual, including what the treatment is, what will be included, and any potential risks and benefits

4. Any alternate procedures that are available

Some of the people with whom we work have a limited capacity to understand all the details of service and treatment. It is our task to find an appropriate balance between too much and too little information and to make our information clear and easy to understand.

Informed consent consists of the following three parts, or criteria. All must be present in order to say that the individual gave informed consent:

1. Capacity. The individual has the ability or capacity to make clear, competent decisions in his or her own behalf.

2. Comprehension of information. The person clearly understands what is being told to him or her. To make sure that this is so, give your information care- fully and always check to be sure the person understands what you have told him or her.

3. Voluntariness. The person gives his or her consent freely with no coercion or pressure from the agency or the professional offering the service.

Currently laws and courts are recognizing more and more often the person’s right to self-determination. When we fail to tell those we serve the information they need in order to give informed consent, we run the risk of being found negligent, particularly if the treatment or service involved was unusual.

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Chapter 2 Ethics and Other Professional Responsibilities 47

The Right to be Informed of Changes and Decision

There are times, however, when you are working with a person who cannot participate. People who are confused, have severe developmental disabilities, or are psychotic often are not capable of planning or giving input. Letting them know what will happen is still respectful. One case manager’s client, Mindy, was hospitalized when she became psychotic as a result of schizophrenia. Mindy barely responded to treatment and the decision was made to transfer her to a long-term care facility. The nurses on the hospital unit made the arrangements for transportation and who would help with the transfer from the unit to the ambulance.

The case manager had agreed to the transfer and came in a few hours before it was to take place to talk to Mindy about it. The nurses were incredulous. Mindy was in a room with only a mattress on the floor because she had taken her room apart several times. She was uncommunicative and had been yelling at voices she heard. “She isn’t going to understand a word you tell her,” one of the nurses remarked. Nevertheless, the case manager went to Mindy’s room, sat down on the bare mattress on the floor and began to describe in some detail what was going to happen. Mindy grew quiet. She never looked at her case manager, but she appeared to be listening intently. When the orderlies came to take her to the ambulance she went without resistance.

Did Mindy really understand what her case manager told her? Is that really the point? The point is that this case manager respected her client’s right to know what plans had been made for her. The right to know what treatments and services have been planned and the right to participate to the degree a person is capable are impor- tant ways professionals demonstrate respect for the people they serve.

Confidentiality

Confidentiality is both an ethical principle and a legal right. It is the most basic right of any person, either in treatment or receiving services, to know that what the person is sharing in your office will remain confidential. It is important to protect individu- als to whom we give service by not disclosing their personal situations without the people having authorized such a disclosure. Today, under new laws discussed in the text that follows, agencies have very specific guidelines for protecting confidentiality.

Release of Information Form

Not many years ago a person seeking services, particularly from a public agency, signed a blanket permission statement allowing information to be shared with others as the agency and the worker saw fit. Today, release of information forms must state specifically to whom the information is being released and must be time limited (good for 3 months, 1 year, and so on). Do not use forms that are not specific in this manner. New regulations now stipulate what is permissible on a release of information form.

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48 Section 1 Foundations for Best Practice in Case Management

Release of Information Regarding HIV/AIDS

In most states, release of information forms for releasing information regarding a client’s HIV/AIDS status must specifically state that you may release information regarding the person’s HIV status. All references to HIV/AIDS must be deleted from the record unless the client signs a separate form that specifically states that you have permission to release this information. If you are asked to release information about a person who is HIV+ and the person signs a release form, the law in most states specifies that it is not good enough to simply remind that person that his case contains references to his HIV status and get his verbal permission to release the information anyway. You also must have his written permission. If the person has not given you written permission, you must delete all references to HIV/AIDS, including the fact that he may have been tested and the test was negative.

If your state does not have such a law, you are still responsible for protecting your client and must be alert to the possible harm such a release might cause the person. In such a situation, it is wise to involve the person in a discussion about the release of this sort of information or, if the individual is unable to participate in such a discussion, to take steps to protect that individual from undue bias.

In some instances, workers have informally notified their friends and acquaintances in other agencies of a person’s HIV+ status, thinking they were doing these people a favor. In fact, this behavior is entirely unethical and can lull other workers into believing they know who is and who is not HIV+. We can never actually know this for certain because of the length of time it takes for the disease to register positive on a blood test. A person can be positive early in the illness and still have negative blood tests. For this reason, workers should use universal precautions with every client when those precautions are called for. Workers who fail to use universal precautions on the false assumption that they know the individual is not HIV+ place themselves at undue risk.

AssIgnmEnT

Find out what the laws are in your state for releasing information about a client that contains references to the client’s HIV status.

Collegial Sharing

Out of respect for individuals, you should ask them for permission before sharing information with colleagues from whom you are getting opinions or supervi- sion, unless the case is going to be discussed in the normal course of supervisory meetings with a regular supervisor. Likewise, you cannot share information with student interns without making certain the students have signed agreements to observe strict confidentiality while acting as part of the agency. Suppose you are working in an agency and have been asked to give a student a view of what you do. To illustrate what you have told the student, you show her several case files.

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Chapter 2 Ethics and Other Professional Responsibilities 49

She reads the cases and discovers that one of them is the boyfriend of her cousin. What she reads in the file is alarming to her, and she decides her cousin should not be dating the client. She leaves the agency and begins to share information with the cousin, causing considerable conflict among family members and anguish to the cousin, who knew part of the story but not all of it. This kind of sharing of in- formation is unacceptable, and most agencies do not allow students or volunteers to read anything before they have signed a pledge to honor the confidentiality of the clients and you feel these students thoroughly understand the critical impor- tance of protecting confidentiality.

Guarding Confidentiality on the Phone and in Other Conversations

Other situations also provide opportunities for violating confidentiality. For instance, a person receiving services from your agency may also be receiving services from a local physician. Suppose someone calls, claiming to be the physician’s nurse and needing to know at once what medications the client is taking. She may really be the physician’s nurse, or she may be a person posing as the nurse in order to determine that the person is using your services and the level of his problem. Even if she is the nurse, the person may wish to keep his physician uninformed about the involvement with your agency. All agencies have procedures for such situations in the event of a real emergency. You, however, must never openly and automatically acknowledge that an individual is being seen in your agency, no matter how important and official the other person seems to be. In the case of a seeming emergency, refer the call to your supervisor unless you know the emergency workers or emergency room personnel well enough to recognize their voices.

When a request for information is presented in a situation that is not an emergency, here is how you might handle the request:

you: Hello.

caller: Hi. This is Ann Taylor. I’m a counselor at Marlboro Middle School, and I’m calling about Jimmy Smith. Did he and his mother keep their appointment with you today?

you: I’m sorry, I can’t help you with that. Would you have Mrs. Smith sign a release of information form stating what it is you need to know, and if Jimmy Smith is known to us, we can send you that information.

In this situation you do not give any hint that the client is known to your agency. By saying “if this person is known to us . . . ,” you do avoid letting on whether the client is or is not known to you.

Another way to violate confidentiality is to talk about your cases with your friends and relatives, leaving out the names. Others may be able to piece together the identity of the person you are talking about based on other information they possess. In this way, they may discover far more about a person than that person ever intended them to know.

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50 Section 1 Foundations for Best Practice in Case Management

Minors and the Infirm

Take special care to protect the confidentiality of minors and the infirm (individuals who are frail, sick, and are unable to fully participate in decisions about their care). Not all systems respect confidentiality to the degree that we in the helping professions are committed to doing it.

In one children’s case management unit, parents were routinely urged to sign blanket release of information forms. When the school requested information on a child being seen, all the information was sent to the school. It was stamped in red letters with the word confidential, and it was sent to the school psychologist. Nevertheless, school clerical personnel assisted in typing and filing information for the psychologist and generally read the information sent by the case management unit. Having no training in confidentiality, these clerical people talked among them- selves about students, sharing personal information they had learned. Many times they passed on to teachers tidbits of what amounted to gossip. This information shared outside the professional context and without professional understanding jeopardized the progress of the children and the relationship of their parents with the school per- sonnel. As these children moved through the school system, the gossip followed them. Always be very careful about what information you release. Remember that informa- tion given about a child can follow that child all through school, prejudicing responses to that child.

In another case, a woman with a developmental disability got a job at the police department as a cleaning woman. She was told that she needed to bring in her “records from mental health” so the police could know why she went there. She arrived at the case management unit, pleased about the job and ready to give all her records away. The case manager talked to her about the wisdom of retaining most of the information as confidential. In the end, a short statement was released, with the client’s permission, giving only the most general information about her relation- ship with the mental health case management unit. It is important to remember that older people or individuals who do not have the capacity to protect themselves can be easily led to sign releases regarding information that might best be kept confidential. The responsibility belongs to you to protect your clients from unnecessary intrusions into their personal information.

Minimum Necessary Rule

Before releasing information, ask yourself whether you are about to release more information than is needed for this other business or organization to accomplish its work with the client. For example, Melissa was a case manager who knew a worker in a remedial education program where one of her clients, Jill, was attending. Although the program needed to know why Jill was referred and what goal the referral was intended to accomplish, they did not need to know that Jill was arrested once for a DUI and that Jill’s father was in prison for murdering a neighbor. When dealing with other organizations not engaged in treatment, release only what that organization

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Chapter 2 Ethics and Other Professional Responsibilities 51

needs to work effectively with the client. If the client authorizes you in writing to disclose more, only then would you do so.

When You Can Break Confidentiality

The law in all states does make exceptions. The following are circumstances that allow you to break confidentiality:

1. When you must warn and protect others from possible harmful actions by the client. For instance, you or your agency must warn another party if your client is intent on harming that other party. In addition, you should notify the police.

2. When the person needs professional services. For instance, if the person has taken an overdose of medication and is in the emergency room (ER), the ER staff may call, needing to know what prescriptions the client was taking in order to give the proper antidote.

3. When you must protect people from harming themselves. An example might be people who are threatening to take an overdose of their medications with the intention of committing suicide or people who appear so depressed or desperate that they are talking about ending their lives.

4. When you are attempting to obtain payment for services and the payment has not been made. Your agency would refer a person for nonpayment only after r easonable attempts had been made to remind the person of this obligation and only if the individual had made no effort to arrange even minimal payment.

5. When obtaining a professional consultation from your supervisor regarding how best to proceed with a case in the course of normal supervision.

Privacy

Privacy is very much related to confidentiality. Siegel (1993, p. 105) calls it “the free- dom of individuals to choose for themselves the time and the circumstances under which and the extent to which their beliefs, behaviors, and opinions are to be shared.” Stadler (1990, p. 102) calls it “the right of persons to choose what others may know about them and under what circumstances.” Kirst-Ashman and Hull (2009, p. 376) define privacy as “the condition of being free from unauthorized observation or intru- sion.” In the social services, privacy is invaded or altered under some circumstances, and people need to be informed of those circumstances. The point you should stress with the people you serve is the fact that third-party payers will have access to diag- noses and, in some cases, to actual records or summaries of records. The agency must provide this access in order to be paid for the services it has rendered. Many individu- als are unaware of this fact or unaware of the extent of the information being shared. They should have this situation explained to them. This allows people to make an informed decision about whether to pay for services themselves and not involve the insurance company.

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52 Section 1 Foundations for Best Practice in Case Management

Health Insurance Portability and Accountability Act

The federal Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 in part to ensure that people did not lose medical coverage when they changed jobs. Title II of the act contains the security and privacy mandates. These con- tain stringent rules for protecting a client’s health information, and most social service agencies must adhere to these rules. Where state laws are more stringent than this federal act, the state laws take precedence. Failure to follow the guidelines set forth in HIPAA can result in fines from $100 to $250,000 and from 1 to 10 years in prison for those indi- viduals and institutions with the ultimate responsibility for safeguarding patient privacy.

The new rules apply to case management and to care coordination and cover not only formal records but also personal notes and billing information. When you begin work at your agency, they will see that you are informed of their policies and procedures under this act.

Disclosure

Under the new rules, “disclosure” is defined as occurring when health information is released, transferred, or divulged outside the agency. This includes allowing access to patient files to others not working for the agency. The material in question is often referred to as protected health information(PHI).

Agency Requirements

In order to comply with HIPAA, every agency must have the following:

1. A statement of the agency’s privacy and confidentiality procedures, particularly as it relates to releasing patient information. This statement must be given to every client of the agency. It is considered a notice clarifying how health information will be used and stipulating the client’s privacy rights. This is a public document and can be posted in waiting rooms and on websites.

2. A form that people sign and return to the agency indicating that they have received the statement on confidentiality policies.

3. A privacy officer who is familiar with HIPAA requirements and can oversee implementation within the agency and resolve privacy issues as they arise.

4. A set of safeguards to protect client records.

The privacy concerns addressed by HIPAA were raised because of the increasing demand by insurance companies, employers, and others for detailed information on clients and patients, often in excess of what was necessary to process claims.

Security and Privacy

Security in the act refers to procedures to protect health information from inappropriate access by others. These procedures usually include controls on who

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Chapter 2 Ethics and Other Professional Responsibilities 53

has physical access to the records, security of work areas and record storage areas, and destruction of duplicate or obsolete files. Electronic security measures are also instituted, such as changing passwords and encryption.

Privacy refers to the person’s right to keep specific information private and includes the agency’s release of information policies and the rights of the individual in this matter. The law is stringent because personal health information has been taken and used for illegal purposes. Workers with access to PHI have used this information for identity theft, sold it to others who then exploited the patient’s situation, used the information to threaten or blackmail others, or took the information to use at another time and location. The penalties can be stiff.

For example, in 2011, a 62-year-old psychiatrist was charged with HIPAA violations when he discussed a woman’s psychiatric case with three individuals seek- ing information on behalf of the patient’s employer. While the woman’s discharge summary indicated she was not a threat to herself or the public, the psychiatrist exag- gerated her condition without the woman’s knowledge or permission. In this case the psychiatrist was fined $5000.00 and ordered to complete an 8 hour course on medical ethics.

Sometimes workers share information to be helpful or to feel important. Frieda knew that the other parents in her daughter’s day care were concerned about the behavior of another toddler in the class. Frieda knew the toddler’s home conditions were chaotic because she was the case manager for the fam- ily. The  parents were getting a divorce, and the mother seemed to be somewhat unstable emotionally. As a consequence there had been long custody battles and a bitterly acrimonious home life for this toddler. Frieda confided this informa- tion to parents who expressed concern about the toddler in her hearing. She felt important that she knew the background to this toddler’s situation and had infor- mation others did not have. Frieda also felt that people would like her because she had chosen to confide private and “secret” information to them. Confiding personal health information to others in violation of privacy stipulations outlined in HIPAA can create legal issues for you and for your agency. The toddler’s fam- ily, who could agree on nothing else, did come together to sue Frieda’s agency for the violation of their confidentiality and Frieda lost her job and her reputation as a competent professional.

Oral Communications

The law states that agencies are to make “reasonable efforts” to safeguard clients’ information. This extends to oral communications. Taking precautions to protect oral communications means:

• Not discussing a person’s personal health information where others can hear • Avoiding situations with clients where there is no privacy, particularly privacy

from other clients • Lowering your voice when discussing clients with others in the agency

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54 Section 1 Foundations for Best Practice in Case Management

Release of Information Form

Under HIPAA, the form signed by the person or a legal representative of the person must adhere to the following:

• The entire form must be in plain, understandable language, and it must be signed and dated.

• There must be a description of the information to be used. • The form must name the recipients of this information. • Those who will disclose the information, such as the agency or a therapist, must

be named on the form. • The form must have an expiration date. • There must be a statement describing the purpose of releasing the information. • There must be instructions telling the client how to revoke the form. • A statement must be included to indicate that the information may not be as

protected once it is released. • If the agency will receive money for the information (for example, payment from

an insurance company), this must be stated on the form. • The form must make clear clients’ rights to a copy of the authorization they have

signed.

It is assumed that reasonable steps will be taken to release only the minimum information necessary to support the purpose of the release. When the purpose is continued care of the person or when the person requests that more information be released, it is expected that more information will be released. Any request for the entire client record, however, needs detailed justification.

Individually Identifiable Health Information

Individually identifiable health information includes demographic information (such as age, gender, income, or race) and other information that identifies the individual or could reasonably be thought to identify the individual. Information that relates to an individual’s past, present, or future condition is also included in this category.

People have the right to ask that their information be restricted. They may indicate, again in writing, that information is not to be shared with family or friends. These requests are generally honored except in medical emergencies. In addition, clients may ask, in writing, that mail from the agency not be sent to their home address or that calls from the agency not be made to their home telephone, and the agency must honor these requests.

A client may ask, in writing, for a written list of how their PHI was disclosed. The request can extend as far back as 6 years. Note that clients can specifically request how information is to be shared or restricted, but must always do so in writing. A person not able to write such a request may need the help of a case manager.

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Chapter 2 Ethics and Other Professional Responsibilities 55

Accessing the File

Under the HIPAA guidelines, people now have a right to:

1. Read their files 2. Make copies of their records 3. Make corrections or additions to their files, as long as the changes are accurate

As noted earlier, such requests must be presented in writing to the agency and must be accommodated within a specific time period. Individuals who are going to amend their files must state the reason for amending the record in the written re- quest. Client representatives, such as guardians, have the same access and rights as do clients. There may be times when the person will need the help of the case manager to formulate that request.

The rights discussed here are guaranteed under federal law; thus, it is illegal to discourage or threaten people when they make these requests. Currently there is evidence that people who have read their charts and received clear information are less likely to sue for malpractice or create other legal problems. It is not a good idea, however, to just hand someone a chart and provide no explanations for technical in- formation that may be written there. This potentially creates misunderstanding. If at all possible, sit with the individual and carefully review the important points in the chart. Answer questions and explain what has been written so the person understands what is written and does not draw erroneous conclusions or conclusions that could lead the person to believe there is an adversarial relationship described in the chart.

social networking

We think of social networking as something we do with friends, entirely unrelated to our work, an activity we engage in on our own time. Contributions to Facebook, Twitter, and other social network sites are assumed to be private and just among friends. In reporting on nurses fired for posting on Facebook, WHTM abc27News (Harrisburg, Pennsylvania) noted, “So you’re in your own home, on your own computer, on your own time, typing on Facebook. It could be your undoing.”

During the winter of 2010, a group of about 13 emergency room workers were fired from a major hospital in Harrisburg, Pennsylvania, for their social networking activities, activities they assumed to be private. In this case, the emergency room workers had estab- lished a Facebook page where they discussed their day’s activities with one another. While no patients were actually named, patients were referred to in exasperated and derogatory terms and their illnesses and personal characteristics were described in some detail.

The article quotes one nurse as saying, “The one posting I put was, ‘That lady was crazy.’ There was no name mentioned, those were the only four words I said.” However, the hospital fired this woman who was shocked. “I would never have thought that what I posted in the privacy of my own home would have ever ended up being the big mess that it is,” she said.

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56 Section 1 Foundations for Best Practice in Case Management

The workers contended that because the page was unrelated to their work at the hospital and activities on the page took place on their own time, they should not be fired. The hospital argued that the page violated HIPAA laws in that anyone who had access to the page could put enough information together to identify individual patients. Social networking pages are generally not as private as we like to assume. Friends of friends can gain access, sometimes inadvertently. In this case the nurses and others did not exercise good ethical judgment. Anyone coming across this site would not have felt comfortable using emergency room services at this hospital.

Many ethical codes have not caught up with social networking as an ethical consideration. That does not excuse you or others from exercising sound judgment about when, with whom, and how you discuss your clients.

Privileged Communication

Clients and workers alike talk about privileged communication without truly knowing what it is. First of all, it is a legal concept. It protects the right of a person to withhold information in a court proceeding. It is a right that belongs to the client. It does not belong to the worker or the agency.

All states have a law that stipulates what communication between a client and professional shall be considered privileged in order to protect the client from the disclosure of confidential information during a court proceeding. These laws designate who is to be considered a professional. A number of years ago there was a case in which a man who committed a murder confessed this murder in an Alcoholics Anonymous (AA) group. He tried to invoke the right of privileged communication, but the courts denied it because the state law did not specifically name AA as a group protected by this statute.

Only clients can invoke privileged communication in order to protect them- selves. Professionals and agencies cannot use it to protect themselves. If the client waives the right to privileged communication, the professional or agency has no grounds to withhold information. Clients waive this right if they sue your agency or if they use their condition as a defense in a legal proceeding.

When You Can give Information

At certain times, you can provide information about people in a court proceeding. In some situations, you are required to do so.

Legal Proceedings

In a legal proceeding, you may give information about people under the following conditions:

1. You are acting in a court-appointed capacity, such as that of guardian or payee. 2. You or your agency is sued for malpractice. 3. The court mandates that you turn over certain information. 4. The individual uses a mental condition as a defense or as a claim in a civil action.

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Chapter 2 Ethics and Other Professional Responsibilities 57

Protecting Clients and Others from Harm

Other situations in which you can give information about people relate to your responsibility to protect clients and those connected with them from harm. These situations are:

1. When you believe the person intends to commit suicide 2. When a child under 16 years old is believed to be the victim of a crime such as

sexual or physical abuse or sexual exploitation 3. When you determine the person needs to be hospitalized for a mental condition 4. When the person has told you of his intention to commit a crime, harm another

person, or harm himself

Intention to Harm Another On October 27, 1969, Prosenjit Poddar killed Tatiana Tarasoff and set in motion court proceedings that brought about changes in the way confidentiality is viewed. That October, Poddar was a patient of Dr. Lawrence Moore at Cowell Memorial Hospital at the University of California, Berkeley. Moore, a psy- chologist, was told by Poddar of his intention to kill Tatiana Tarasoff. Moore contacted campus police, who briefly detained Poddar but released him when he appeared to the police to be rational. Apparently, Dr. Powelson, Moore’s supervisor, directed that no further action be taken to detain Poddar. No one warned Tatiana Tarasoff of the danger she faced, and as a result she lost her life.

The Tarasoffs brought charges against the professionals in this case for failure to warn the victim of the impending danger. When the California Supreme Court even- tually heard the case, the court ruled that

therapists cannot escape liability merely because Tatiana herself was not their patient. When a therapist determines . . . that his patient presents a se- rious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger. (Tarasoff v.  Regents of the University of California, 1976)

The steps the court included were warning the intended victim, warning others who would apprise the intended victim of the danger, and warning the police. The court went on to state:

We recognize the public interest in supporting effective treatment of mental illness and in protecting the rights of patients to privacy, and the conse- quent public importance of safeguarding the confidential character of psy- chotherapeutic communication. Against this interest, however, we must weigh the public interest in safety from violent assault.

The opinion closed with the following:

We conclude that the public policy favoring protection of the confidential character of patient-psychotherapist communication must yield to the extent to which disclosure is essential to avert danger to others. The pro- tective privilege ends where the public peril begins.

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58 Section 1 Foundations for Best Practice in Case Management

This case established a “duty to protect” for individuals who treat patients who appear to present an imminent danger to an identifiable person or persons. The ruling appears to apply mainly to therapists, but here the waters are muddy. Human service professionals in all states have taken the position that if such circumstances were to occur in the course of their work, the courts would find them negligent if they had not exercised the precautions laid out in the Tarasoff case. Most states now have statutory or binding case law that establishes the duty to warn, but some do not. Regardless, you must assume that the courts would find you or your agency negligent if you failed to take the precautions outlined in the Tarasoff ruling. It is unlikely that you would be excused from liability because you are a case manager, and not a therapist.

Rarely would you make the decision to warn alone. If you believe a person poses an imminent danger to another identifiable person or persons, you must take the mat- ter up at once with your supervisor. If your supervisor is not available for consultation and you believe you cannot wait, notify the police.

In a step down unit for the mentally ill, a man living there left one evening. No one knew where he was going, and when he didn’t come home that late evening, the staff became alarmed. He had been talking about going back to the farm where he grew up to “evict those people who put us out.” In fact, the family had sold the farm, and the people living there were the owners. At this point, the worker determined that the family at the farm should be warned. The supervisor, unfamiliar with the law, resisted, even though she would have ultimately been responsible had something happened. Later the worker ran into the director of the agency and asked her opinion. Immediately the director told the worker to contact the people at the farm and let the police in that jurisdiction know he might come to the farm. In fact, the man did show up and talked about the need for the owners to move out. He did not pose a threat, but the fact that he might have done so was important to consider. In this case, the police returned him to the step down unit where his behavior was discussed with him. This supervisor’s lack of understanding about the law could have caused problems for the client, the people living at the farm, and the agency.

AssIgnmEnT

Find out what laws exist in your state regarding your duty to warn or your duty to protect a third party from harm by your client. There are databases available online that outline the laws or lack of laws in each state. Some states have no laws but rather policies that leave decisions up to the practitioner. If there are no laws on the books or if the laws are extremely permissive, what is common legal opinion regard- ing the duty to warn?

Mandated Reporting

All states have laws that require professionals to report the abuse and neglect of children. These laws make it a criminal offense to refrain from reporting abuse and neglect if you suspect these are going on in a child’s life. In other words, you, as a social service

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Chapter 2 Ethics and Other Professional Responsibilities 59

professional do not have a choice about whether to report or not to report. The law man- dates that you must. In some states, laws require human service workers to report elder abuse as well. The definition of child abuse and elder abuse varies from state to state. Professionals who must report abuse and neglect under the law are called “mandated reporters.” The laws in each state stipulate who is a mandated reporter; variations exist among the states in regard to which professionals are considered mandated to report.

Although there are laws on the books that require you to report abuse and neglect, workers are often guilty of not making the report. The reasons given are many. Some workers feel that reporting abusive parents will ruin a good relationship they have estab- lished with these parents. Some workers feel they do not have enough “proof” of abuse or enough information to report. However, it is not your responsibility to determine if abuse and neglect are taking place. If you have reasonable cause to suspect there is abuse or neglect you must report it. The agency that receives the report, such as child protec- tive services or the district attorney’s office, will make the ultimate determination. If no abuse is found this is not considered in anyway a mark against you. In reporting what you suspected could be going on you have followed the law and the ethics of your profession.

Even in states where there is no mandate to report elder abuse, there may be protective services for the elderly to which you can report suspected abuse of an older person. You have an ethical responsibility not to ignore abuse of this type, regardless of the law. It is your responsibility to protect clients, particularly individuals who can- not protect themselves.

AssIgnmEnT

Find out your state’s definition of child abuse. Learn which professionals in your state are considered mandated reporters of child abuse. What are the laws in your state regarding elder abuse? Who must report elder abuse in your state?

Diagnostic labeling

Agencies that rely on a diagnosis in order to be paid for service by a third-party payer (such as an insurance company, Medicare, or Medicaid) need to inform people of that fact. People rarely understand that labels are used in this way, and most people do not know what the labels are or what they mean. They are rarely clear about the fact that the information will be passed on to their insurance companies. People need to know this, so they can then decide whether to continue to receive services from the agency. Some individuals may elect to leave the agency or to pay for the services themselves, without involving their insurance companies, as a means of ensuring their privacy. Unless they are informed, they will not know they have these choices.

Another point about diagnosing people is that practitioners use the categories of illness to know which treatment to use and how to develop the most effective treatment plan. Much research has been done to link the best treatments with each of the diagnostic categories. People will appreciate the need for a diagnostic label if they understand this. What may appear to people as simple respect, kindness, good

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60 Section 1 Foundations for Best Practice in Case Management

communication, or personal support on the part of their therapists may actually be the use of well-developed treatment modes.

Involuntary Commitment

Generally, an involuntary commitment occurs to a facility that specializes in inpatient mental health care. It could be a unit in a general hospital in the community where the clients live, a private psychiatric hospital, or, in some cases, a partial hospitalization pro- gram where people receive treatment during that portion of the day they are most at risk.

Patients have a right to expect the least restrictive form of treatment. If they need hospitalization but not a locked ward, they should not be locked up 24 hours a day. If they can get the care they need in a partial hospitalization program, they should not have to go into the hospital. In discussing the movement to deinstitutionalize mental patients, Bednar, Bednar, Lambert, and Waite (1991, p. 100–101) wrote, “treatment should be no more harsh, hazardous, or intrusive than necessary to achieve therapeutic aims and to protect clients and others from physical harm.”

The courts take seriously their responsibility to commit individuals in need of psy- chiatric care who are unable to obtain it because of a current severe impairment. In making the commitment, the courts make it clear that the purpose is treatment, and not punish- ment for behavior. For that reason, court commitment proceedings are often less formal and more pleasant than criminal proceedings. Students may observe these proceedings if they choose, as the proceedings are public. If you are involved in a commitment proce- dure, be sure to document all the steps you take in order to protect yourself from liability.

The criteria for committing someone against her will are as follows:

1. The person poses a danger to self or to others, and possibly one or more of the following:

2. The person has a severe mental illness or a mental illness that is currently acute. 3. The person is unable to function in occupational, social, or personal areas. The

impairment is severe enough that the person cannot provide adequate self-care. 4. The person has refused to sign a voluntary commitment for treatment, so that an

involuntary commitment is the last resort; or the person is incapable of signing such a commitment or of choosing appropriate treatment.

5. The person can be treated once committed; that is, known treatments and medications can relieve the acute condition the person is experiencing at present.

6. The commitment adheres to the criteria of the least restrictive treatment setting.

AssIgnmEnT

Find out what the commitment laws are in your state. Look at the various types of voluntary and involuntary commitments. Find out under what circumstances the client can leave a facility when voluntarily committed. Find out what constitutes due process in your state for those being committed involuntarily.

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Chapter 2 Ethics and Other Professional Responsibilities 61

Ethical Responsibilities

Responsibility for the individual’s welfare while the person is in your program is yours. The person views you as an authority. No matter how inexperienced you feel, when people work with you, they will see you as the person with all the answers. For this reason, you will have considerable influence over what your clients decide to do. It is important to keep their needs at the forefront of your planning and delivery of services.

Burdening Clients with Your Problems

Sometimes people in human services use clients to meet their own needs. You could, for instance, burden the person with your own problems. You might say things such as “Oh, that happened to me too” or “Wait until you hear what happened to me!” You might have had a bad day and want to talk to someone about it, and so you tell your client all about it, as Kent did with his client Lucy.

Meeting Your Needs

Do not ask the individual to do something that meets your needs or is not in the best interest of your client. Because of the influence you have with this person, it is easy to influence a client to do something that is beneficial to you. You might get the client in- volved with a friend of yours who sells insurance, or you might ask the client to go on television with you or to do an interview about the client’s condition for the paper. There might be some payoff for you, but because the person could have considerable difficulty saying no to you, it is imperative that you never place your client in this situation. Often the media wants to interview a person with schizophrenia or recovering from alcoholism. Inform members of the media that they will have to locate their own interviewees.

Insisting on Your Solutions

You may have a need to look efficient, innovative, or particularly therapeutic, and so you might try to give your clients solutions to their problems. You may have had a similar problem at one time and feel there is only one good way to resolve it—the way you used to resolve it, a way your clients can use without experiencing the hard knocks you took figuring it out. You might be tempted to lecture, to discuss your situ- ation and how it compares with theirs, or to warn your clients. None of these actions will help your people to grow by finding their own solutions.

Another way you can make people do what you want them to do is to treat them rudely if they fail to use your solutions or to move quickly enough toward a solution. Being rude is not the same thing as being firm. You can set limits, but it is inappropriate to treat people brusquely for not improving or for not taking what you suggest as healthy measures.

Exploiting Dependency

Clients are naturally vulnerable. They come to you at a time in their lives when they are hurt, upset, and disorganized—a time when it is easy to come to rely on another

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62 Section 1 Foundations for Best Practice in Case Management

person. You are in a position to exploit this vulnerability by maintaining the individual in a dependent position long after such dependency is useful for that person. For example, you might enjoy having people call you about the details and decisions of their lives. It might make you feel important or needed. You might encourage them to lean on you for assistance in matters they could manage themselves. Be very careful not to allow this sort of relationship to develop.

In one support group run by a psychiatric nurse, individuals gathered once a week to discuss their problems. Most of the participants were also depressed. A  student, Grace, from the local college joined the group and was an active participant for about 2 years. During that time, the nurse who led the group often went out to lunch with Grace and was extremely encouraging. It appeared in retrospect that the nurse had developed dual relationships with a number of group participants, eating with them, inviting them to her house, and going to plays and concerts with them. The nurse explained that this was her way of supporting her clients.

Grace completed her associate’s degree and her bachelor’s degree before she was ac- cepted at a graduate school in another state. She told the group and the nurse in charge that she was no longer depressed and that she felt she was ready to move on now. She shared her good news about her acceptance to graduate school. Instead of showing pleasure and encouragement, the nurse became angry. She told Grace that she was trying to deny her need for the group and for the nurse. She ridiculed Grace’s acceptance to graduate school, telling Grace she was not ready for such a large step and would surely fail. When Grace continued with her plans, the nurse stopped speaking to Grace and encouraged others to stop speaking to Grace as well. This is an example of a group leader, a worker, who could not tolerate the fact that her clients would not always need her. The group was meeting her needs, which she was clearly putting before the needs of her clients.

Protecting a Person’s self-Esteem

We can all agree that denigration of people, whether through verbal or physical abuse, is unethical, and in some cases illegal. You may believe that you are highly unlikely to encounter such behavior except in extremely unusual cases. Nevertheless, it is wise for you to understand that some workers are tempted to treat people this way. There are four reasons this is likely to happen.

Unpleasant People

Just as in any other walk of life, there are people in social services who are not pleasant people. They are unpleasant in many different aspects of their lives, and they are insensitive to the toll it takes on others, particularly clients who are uncertain of their self-worth.

Need for Power

There are workers whose own sense of self-worth seems uncertain to them. They choose fields where they will have a degree of power over others. In this way they

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Chapter 2 Ethics and Other Professional Responsibilities 63

seek to elevate themselves at the expense of people they can clearly believe are poor souls. These individuals make life difficult for clients simply because they can, because they have the power to do so.

For example, one student reported that while she was on a fieldwork assignment, she and the staff and clients were all having soft drinks together. A client approached the worker in charge and timidly asked if he could have more ice for his drink. The worker responded with, “No, you don’t need any more ice. If your drink is warm, it is because you are so slow drinking it. Go back and join the others and drink up.” After the client turned and walked away, the worker leaned over and helped himself to ice for his drink, laughing as if this was a joke.

Lack of Support for Workers

Social service workers who lack support from their supervisors or administration often lean together for support. They tend to develop a we–them attitude with regard to the clients, feeling the need to do whatever they must to support each other and hold cli- ents apart. In one unit, adolescents were housed together after committing offenses. The least experienced staff came on in the evening, and that is when the teens would challenge the authority of the staff. Calls for help and requests for information and training on how to better handle the evening shift were ignored by the administration. Left alone with little support or knowledge, the staff resorted to coercion, often physical coercion, to manage the disruptive situation. In the end, the staff was blamed for using excessive force, but the lack of support and interest in these workers by supervisors and the administration contributed significantly to the way these adolescents were treated.

Isolated with Unpredictable Behaviors

Workers in group homes, partial programs, or evening residential programs often are left alone without support when clients are exhibiting unpredictable behavior. Fear and a need to control the behavior and the situation can lead workers to use ver- bal, and even physical, abuse. For instance, two workers, one a student in a fieldwork placement and the other out of social work school only a year, were in a group home for the mentally ill. One evening, after one of their clients clearly became manic, the student made a number of calls to supervisors. Supervisors responded irritably. It was their time off, they complained; the workers would have to figure it out for them- selves. That’s what they were being paid to do. A subsequent request to call in the cri- sis team was similarly denied. The two students spent the evening and all night with a client who was increasingly out of control with no supervision or support. Agencies that do not provide good support for less skilled workers are open to having workers band together against the clients in self-defense.

One problem new workers can encounter is finding themselves working for the first time in a place where they question the treatment of clients. If this happens to you, those in charge may tell you that this is the “real world” and that what you learned in school is impractical and does not apply. In these situations, the new work- ers clearly have entered situations that developed among the other workers long ago. Workers who encounter such abusive situations have a choice of either reporting the

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64 Section 1 Foundations for Best Practice in Case Management

abuse or looking for work in a place where people are treated ethically, but they do not have a choice about their own behavior.

Ethically, you are charged with the care of the client. That includes the person’s feelings of worth. Ethically, your behavior toward people should help enhance their view of themselves as worthy. Behaviors on the part of social service workers that subtract from a person’s sense of self-worth are entirely unethical.

stealing from Clients

It goes without saying that it is illegal and certainly unethical to take money or things belonging to clients. We have looked closely at how people lose their privacy. Gossip, giving information to strangers without a release form signed by the client, and releas- ing more information than is needed are all ways that people can lose their privacy or lose control of their information when they are being served by social service person- nel. As previously noted, HIPAA laws outline the right to privacy and the protection of peoples’ health information. However, workers can steal from individuals in other ways without even thinking about it. When you enter other people’s lives and those people are not in a position to protect themselves, they are just as vulnerable as you are when you allow service or repair people into your home when you are not there to protect it.

There are two ways workers steal from clients. Both of these are theft and are entirely unethical:

1. Workers can steal a person’s privacy. 2. Workers can steal a person’s esteem and sense of worth.

Consider how people can be robbed of their self-esteem and self-worth. Vulnerable and unsure of themselves, perhaps feeling awkward and dismayed over needing to ask for help, people come for assistance with precious little self-confidence and self-esteem. What self-esteem they do have is needed for support in their struggle to regain their health or recover from bad habits. Workers have an opportunity at this point to reassure and encourage or to steal that sense of self-esteem and self-worth. It happens when people are denigrated, spoken to rudely or brusquely, called names, or ignored when they are present. It happens when people are made fun of, treated cruelly, shamed, and ridiculed or forced to perform actions they are incapable of performing at the time.

Let’s look at some examples. Kimberly had a long-standing battle with schizophrenia. When her mother was diagnosed as terminally ill, she called a crisis hotline to talk about this pending loss. The day her mother died she called again and the worker replied, “Didn’t we discuss this before?” When Kimberly said they had “but my mother died today,” the worker went on, “well, do you have anything else to talk about because if you don’t you are wasting my time.”

Peter had been sober for 2 months when he began to drink again. He felt bad about it and fearful that he would go on a binge, so he sought out the worker at the detox unit assigned to him. When the worker finally took him into his office, he said to Peter, “So you couldn’t stay off the bottle! What a loser. I guess you know that by now.”

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Chapter 2 Ethics and Other Professional Responsibilities 65

In an after school program for teens with behavior problems, Curt was telling his worker that he could not return to school until he had completed the program. “I have no time for you. Grow up and complete it,” said the worker, and with that she walked out of the room. For the rest of the afternoon and evening she refused to acknowl- edge Curt, invite him to eat with the others, or respond when he approached her. She would look past him or turn to another client.

I am sure that as you read about these incidents you felt these were egregious examples of workers mistreating clients or patients, but in many settings rude and often unkind communication is used frequently, either because workers feel harried or because they see this as a way of motivating people or because it makes them feel important. For the truly professional worker, it means that you will decide consciously that you will never knowingly subtract from a person any sense of self-worth or self- esteem. If you can make this promise to yourself, you will be conscious of how even your most casual remarks can either steal something of value or enhance the health of the people you help.

Competence

A significant characteristic of professionals is their ability to clearly know their limita- tions. Ethical professionals do not try to do work for which they have not been trained. Recognizing the limits of one’s training and experience is very important. This means that you will be aware of areas where you could use some help or direction and that you will seek assistance when you need assistance. You will ask those who have more experience or education to assist you rather than attempting to do work for which you are not qualified.

In addition, seek additional training throughout your career. Most certification and licensing programs require that individuals obtain further training on a yearly basis. Even if you are not part of such a program, you have an ethical responsibility to increase your skills, knowledge, and understanding of the field in which you work.

Responsibility to Your Colleagues and the Profession

We all have an ethical responsibility to protect our clients. Sometimes our clients need to be protected from those who are charged with their care. Nearly every profes- sional code of ethics contains statements supporting the ethical responsibility of the professional to take action when a colleague is no longer able to function effectively or is openly violating ethical guidelines.

Impaired Workers

A social service worker is considered impaired when he or she is no longer functioning effectively due to substance abuse, mental illness, or personal problems.

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66 Section 1 Foundations for Best Practice in Case Management

In such cases impaired workers are so consumed with their problems that they are no longer able to focus on the needs of clients. In other words, they are distracted, focused on things other than their professional responsibilities, and often neglectful to the point of endangering clients.

If someone with Whom You Work Becomes Impaired If you find yourself in a situation where a coworker appears to be impaired and therefore unable to be effective, you have an ethical obligation to take action. Generally, the first action to take is to talk privately with the person who seems to be having problems. Point out your concerns and listen to any explanations you receive. Explore ways to help the person resolve the problems.

Usually agencies have established procedures for handling concerns about colleagues who are thought to be impaired. Sometimes, if the person holds a profes- sional license, the licensing board is notified so it can take appropriate steps to curtail the individual’s opportunity to practice until the personal problems are resolved.

In one outpatient unit where clients received medications, it became obvious that one of the RNs was taking some medication for herself. At first the staff was not sure how to handle this. The RN was the supervisor. She did the pill count, but the workers noticed that clients ran out of medications sooner than expected with numer- ous seemingly reasonable explanations. The staff was torn between wanting to let someone know and fearing that they could be wrong. Finally, in a staff meeting one member remarked that she was concerned that the clients were so often out of medi- cation and she wanted to better understand how that happened so the agency could take steps to correct it. When the RN became defensive and refused to participate in the discussion, the staff went with their concerns to the administration.

If you have concerns about how to proceed, it is useful to discuss your concerns with a senior professional. Here you may be able to clarify whether and to what extent clients are endangered by the behavior you have observed, and how the behavior indicates that your colleague is impaired.

If You Become Impaired

Ethically, you have a responsibility to refrain from activities that may lead to your own impairment. Should you become impaired for whatever reason, you have a further ethical responsibility to resolve your problems if they will interfere with your ability to practice. Practicing with clients if your physical, mental, or emotional problems will interfere to the detriment of the clients is unethical. It is important to have good self- awareness and be alert to the possibility that personal problems are interfering and having a negative impact in your work with clients. If this is the case, you have an ethical responsibility to seek help and to limit or cease your work with clients until your own problems are resolved.

Roy had had a drinking problem off and on all his adult life. He managed to hide it well enough to function in college and in his work as a case manager for many years. When his wife left, however, he began to drink more and missed work more consistently. A coworker noticed the problem and talked to Roy about getting help,

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Chapter 2 Ethics and Other Professional Responsibilities 67

but Roy brushed him off. Soon after, Roy began seeing one of the clients who also had a drinking problem and had come to the center for both her depression and her alcoholism. Roy kept this relationship secret, and the couple drank in bars that other case managers would not frequent. One night Roy and his girlfriend got into a fight at the bar where they had gone after dinner. The bartender asked them to leave; the fight moved to the street, Roy beat his girlfriend, and the police were called. Only when Roy ended up in jail, his career and marriage in a shambles, and his addiction out of control did he sober up enough to agree he needed help. Roy served his time, was terminated from his position as a case manager, and began outpatient treatment for his addiction. He is currently working as a night watchman for a furniture store.

It is often difficult to admit that we have problems, particularly when we work in a field where people expect us to have healthy answers to their issues. Nevertheless, problems are part of life and they always present opportunities for growth. Denying our own problems is not healthy and further impairs our ability to be useful social service workers in the future. Address your own problems as they occur as part of a lifelong pursuit of health and wisdom.

Ethical Violations

This chapter has put forward some of the common ethical standards and issues you will encounter, but it is not entirely comprehensive. You may encounter situations in which you have questions about what is ethical and what is not. Consult your code of ethics and talk to senior professionals about your concerns. Not all situations present clear-cut ethical options.

Sometimes you may have a colleague who is seemingly violating an ethical principle. A discussion with your colleague about your concerns is often the first step you might take, describing what you have observed and your concerns about your observations. If no satisfactory resolution results, you must then express your concerns to senior professionals or the administration in order to end the unethical behavior. Your agency will likely have a procedure for reporting unethical behavior; if so, that procedure should be followed.

Professional Responsibility

Finally, remember that you represent an agency and that it is your responsibility to establish a relationship with your clients and your community that is befitting of the agency. This will affect your relationship with clients in two ways.

First, know the parameters of your agency and operate within them. If you work for an agency that gives out food and fuel to the poor, do not attempt to do mental health counseling. If you are a case manager in a drug and alcohol unit, do not attempt to arrange foster care for one of your client’s children except through the agency des- ignated to handle that. If you work in a shelter for battered women, do not try to do drug rehabilitation. When a person needs services that fall outside the particular focus of your agency, make a referral to another agency that can best handle the problem.

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68 Section 1 Foundations for Best Practice in Case Management

The second way your relationship with the client is affected is related to dual relationships. Remain professional. Limit your contact to the focus of your agency and to the focus of that particular person’s problems. Do not invite people home to dinner, take them home with you for the night, or become socially involved with them because you feel sorry for them.

Perhaps you are in the ER giving assistance to a woman who has been raped in her home. You are working for a rape crisis center. It is late. The woman you are inter- viewing is terrified of going home. You call crisis intervention to arrange for temporary lodging, but they are currently out of the office on a call and will have to “get back to you.” The woman has tried unsuccessfully to reach two family members but has reached only their answering machines. Finally, in desperation, you take the woman home with you. You would rather do this than sit in the ER all night because you have to be at a meeting in the morning. The woman is educated and seems very pleasant and refined. She goes home with you, spends the night at your house, and returns with you to the agency in the morning, where they help her obtain temporary housing and see that she gets safely to work.

Two months later you begin to receive calls from the woman, who seems to want a friendship with you. She has found your number in the phone book. Soon after this, you receive a call in the middle of the night. It is the same client. She has had a fight with her boyfriend, and now she wants to stay with you. You tell her she cannot do that, and she becomes hysterical. In the next several weeks, she appears at your house several times, asking to stay with you. Always there is some reason she cannot stay where she is currently living. She knows your phone number, so she calls frequently. You have to be very firm in order to set limits; sometimes it is hard to do.

This story about a worker taking someone home is not all that unusual; it does happen. Rarely, however, is a person who is hurting and vulnerable able to reestablish a professional relationship with such a worker, complete with boundaries and limits, once the worker has extended this kind of friendship or kindness.

summary

This chapter is particularly important because it involves your ethical obligation to the client and outlines some legal concepts you must follow to protect your client and yourself. The primary issue is always the welfare of the client. That must come before all other considerations. When we choose this line of work, we deliberately choose to work with vulnerable people who cannot be expected to protect themselves or to know their rights. It becomes our responsibility to see that clients are well protected and are treated or given service under the highest ethical standards.

Common codes of ethics, including the Code of Ethics of the National Association of Social Workers (NASW) and the Ethical Standards of Human Service Professionals, can be found in Codes of Ethics for the Helping Professions (Brooks/Cole, 2004).

Now that you are thoroughly familiar with your ethical and legal responsibilities, it is time to turn to case management as a basic area of practice in which ethical behavior is expected and informs your decisions.

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Chapter 2 Ethics and Other Professional Responsibilities 69

Video Examples

To view the videos that accompany this book, go to CengageBrain.com.

• “An Ethical Issue”—Because ethical decisions are often not clear or vary from one situation to another, it is a good idea to discuss your thoughts and concerns about how to proceed with another person. Another person is often able to sort out things from a different perspective. In “An Ethical Issue,” two case managers are discuss- ing whether or not to break confidentiality. They look over the good reasons to do so and reasons breaking confidentiality might not be appropriate.

Exercises

These exercises can also be filled out online at CengageBrain.com.

Exercises I: Ethics

Instructions: The hypothetical practice situations that follow are designed to stimulate thinking and discussion on the issue of confidentiality. Each situation is followed by a multiple-choice list of possible responses you might make. Choose the responses that you consider the best. In some cases you might want to use more than one of the responses listed. Others may choose a different answer. Discuss with your fellow stu- dents the different possibilities and what might present the best outcome for the client.

1. Paula is a 17-year-old client in the daytime partial hospitalization program. Her mother phoned and requested to know Paula’s psychiatric diagnosis so that she could inform the family’s physician who is treating Paula for diabetes. You should:

a. Advise the mother of the diagnosis and the name of the psychiatrist who made the diagnosis.

b. Call the family physician directly and advise him of the diagnosis. c. Ask Paula to sign a release of information form giving consent for the

physician and the mother to be advised of her diagnosis. d. Refuse to release the information at all.

2. Kelly requests a copy of his current treatment plan. You should:

a. Have Kelly put the request in writing and discuss the issue with the treatment team.

b. Make a copy of the current treatment plan and give it to Kelly. c. Discuss the treatment plan with Kelly and then see that he has a copy. d. Refer Kelly to the attending psychiatric physician.

3. A 13-year-old boy requests that his school counselor be sent a copy of his initial interview and discharge summary. He signs a release of information form, docu- menting his written consent for the information to be transmitted. You should:

a. Forward the material to the school counselor. b. Give the information to the boy who can deliver it to the school counselor.

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70 Section 1 Foundations for Best Practice in Case Management

c. Have the medical records department forward the information to the school counselor.

d. Refuse to release the information until a parent cosigns the release of information form.

4. In the case above you would

a. Release the complete chart b. Release just the discharge summary c. Release only those portions of the discharge summary that the school needs

for their work with the boy and not release the initial intake summary as it contains information that is no longer relevant but taken out of context could be damaging to the boy’s family

d. Meet with the parents to go over what you have decided to release as outlined in C before anything is released to the school.

5. Mary Smith is a depressed elderly woman who was admitted to Polyclinic Hospital due to severe back pain. She was advised she might need surgery to correct the problem. You are her case manager at the Office of Aging, and she calls to say she is considering suicide. The constant back pain has made her feel like “just giving up.” Mary is currently at home, awaiting a surgery date. You know Mary has a supply of pain pills, and she says she wants to take all the pills. You feel there is a substantial risk that Mary might follow through on her threat. You should:

a. Contact the Polyclinic orthopedic staff who are currently seeing Mary in the outpatient clinic.

b. Maintain frequent contact with Mary, but respect her wishes to keep her suicide plans confidential.

c. After discussing with Mary what you are about to do, contact crisis intervention.

d. Advise the city police department of Mary’s suicide plans.

6. Bill Jones is a client who has been in alcohol treatment programs at your facility. He is currently depressed about his pending divorce and present marital separation. He has signed a release of information form for you to share information with his priest, who is counseling Bill about his religious conflicts regarding the divorce. A man calls you claiming to be Bill’s priest and requesting information on Bill’s current state of mind. You have never actually spoken with Bill’s priest, and you think this might actually be Bill’s wife’s attorney calling. You should:

a. Give no information on the phone until you have verified the identity of the caller.

b. Refer the caller to Bill, but send the information to the person at the address on the release form Bill signed.

c. Insist upon meeting with the priest in person. d. Share no information with the caller and contact Bill e. Get the person’s number and call him back.

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Chapter 2 Ethics and Other Professional Responsibilities 71

7. Patty is completing a student internship for her associate’s degree in the therapeutic activities program. She asks to review the medical records of the people who were just in her projects group. You are supervising Patty. You should:

a. Advise Patty that the records are confidential and may not be inspected by students.

b. Make certain that Patty is well trained in the policies and procedures relating to confidential information, and only then allow her access to the medical records.

c. Permit Patty free access to the records because she is like part of the staff. d. Obtain written consent from each client for Patty to review the records.

8. Jerry was a client who improved and was discharged 2 years ago. You receive a call from the National Can Company. The caller explains that Jerry has applied for a job and that the company would like to hire him. Jerry told them he was in treatment 2 years ago and was discharged after showing considerable improve- ment. The company wishes to confirm the fact that Jerry did indeed complete the program as he claims. You say to the caller:

a. “I don’t know if Jerry was ever a client of our agency. If you send me a release-of-information form I can look into that and get back to you.”

b. “Jerry was a patient here but I am not at liberty to say any more than that without a release-of-information form.”

c. “I can tell you that Jerry was a client here around 2012 and he successfully completed the program with us. I will need a signed release-of-information form from Jerry to put in his file.”

d. “I don’t know what you are talking about. Good-bye.”

9. Clark is currently enrolled in treatment, and you are his case manager. He asks you if he may read his medical record. You should:

a. Ask Clark to put the request in writing, and assist Clark in completing the written request if he seems to have limited skills in reading and writing.

b. Present Clark’s request to Clark’s treatment team. c. If the treatment team concludes that it will not harm Clark to review his

record, allow Clark to read it in the presence of a therapist (after deleting information from sources that asked to remain anonymous).

d. Decide with the treatment team who will assist Clark in reading and understanding his record. Then follow through by allowing Clark to review his record with that person.

Exercises II: Ethically, What Went Wrong?

Instructions: The following hypothetical practice situations are designed to help you apply what you have learned in this chapter. For each situation, decide what was done in the situation that was unethical.

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72 Section 1 Foundations for Best Practice in Case Management

1. Jennifer had a long day and was trying to get out of the office before 5:00 p.m. She had one more person to see. Dr. Adams had asked Jennifer to give Abdul, a young man recently diagnosed with schizophrenia, a prescription for a new medication. Jennifer had her coat on when she handed the prescription to Abdul in the waiting room. Abdul wanted to know what the medication was and why his prescription was being changed. “Will there be any side effects?” he asked Jennifer. She replied hurriedly, “Oh, no. Dr. Adams says just take this until he sees you next time.”

2. Carl is uncomfortable around gay men. Bert, his client, is gay and has just broken up with his lover. Bert, who is 42 years old, had been in a long-term relationship and is devastated and in tears in Carl’s office. Because Bert has suffered from se- vere depression in the past, Carl attempts to have him evaluated by the therapist this afternoon. In the meantime, Bert is still weeping and now threatening to take his life. Carl is particularly uncomfortable with this man’s tears and believes this is drama. Carl says, “Oh, c’mon now. Let’s get a grip. You can’t sit in here all after- noon carrying on. Here, take some tissue and go out in the waiting room until Dr. Paul can see you.”

3. Elizabeth visited the home of an elderly man and got him to sign a release of information form so she could process an application to the county nursing home. In the man’s records were references to the fact that many years ago as a teenager he was convicted of shooting a man in a bar fight, a crime for which he served 2 years in prison. She knows the people at the home will be titillated over this little tidbit of information, especially her friend Rhoda, who does the in- takes. Even though she knows this is not part of the home’s evaluation, that the client has led an exemplary life since that time, and that the nursing home staff might take it out of context, she releases the information anyway, based on her client’s signature on the release form. She and Rhoda have a good laugh about it the next day.

4. Jim is doing an intake with a man who claims he is depressed. He tells Jim that ever since his wife left he has had trouble concentrating and waking up in the morning. He talks about how lonely it is at home, how much he misses his children, how he is tempted to drink in the evenings, and how little he has to look forward to. Jim nods. He understands. “Yes, my wife left last month too,” Jim tells the man. “I know just what you mean. I get to feeling like, well, like there isn’t as much meaning. I never knew the kids were so important to me, but I guess they were. On Saturdays, I used to do things with my son and I still get him every other weekend, but it’s not quite

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Chapter 2 Ethics and Other Professional Responsibilities 73

the same thing, is it?” “No,” the man responds, “I was thinking . . .” Jim interrupts the man to say, “Well, I do a lot of thinking too. I think about what I could have done differently and if it was my fault. Don’t you think these women would see that it’s hard, too hard I think, to raise kids alone?” The conversation continues in this vein until the end of the interview.

5. Carmen is supposed to see her small caseload of persistently mentally ill individuals at least twice a week. Lately, with school and her mother’s death, she has not really seen her clients that often. She has checked in with them on the phone, but she also has used time when she was out seeing clients to do errands at the library and to empty her mother’s home. Now one of her clients is in court after committing a crime. The client and the lawyer agree that the client might be able to use his mental health status as a reason for committing the crime, and they ask to introduce the case record as evidence in the court proceedings. Fearing that it will be discovered how little supervision and attention she has given her client, and knowing that ultimately she could be blamed for the fact that her cli- ent committed the crime while under her somewhat irresponsible care, Carmen invokes the concept of privileged communication to avoid having to give the file to the court.

6. Ted is in a clinic with his elderly client, Gretchen, for a routine blood workup, which they do every other month. He notices Gretchen is bruised on the face and arms. For a while he makes small talk with her, and then he asks her about the bruises. She is somewhat evasive but indicates, “They weren’t the result of no fall!” Without explicitly blaming her daughter and son-in-law, with whom she lives, Gretchen makes it quite clear that the bruises are not the result of an accident. After the blood test, during which neither the doctor, who sees her briefly, nor the technician make any mention of the bruises, Ted takes Gretchen home. He toys with the idea of reporting the bruises to protective services at the county Office of Aging but decides not to. He bases his decision on the fact that the law does not specifically require him to do so, that it would be hard and take a lot of time to have to place Gretchen in another living arrangement, and that the daughter seems like a very nice person whom Ted does not feel like stirring up over an uncomfortable situation.

7. Kitty has a whole list of things to do today and doubts she can get it all done. She hates the way there are always things left to do at the end of the day. It just seems that no matter how hard she works, something new comes up that she cannot complete. One of her clients, Isabel, has told her on the phone that

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74 Section 1 Foundations for Best Practice in Case Management

she wants to sign a release of information form for her lawyer. Kitty has the form ready for the time when Isabel will be coming in at the end of the week. Today a man calls and says he is Isabel’s lawyer and he needs just two dates to help him file a brief with the court on the Isabel’s behalf. Kitty gives him the two dates and hurries to the next thing on her list.

8. While having lunch in the staff room, Jorge is obviously mad. He spent one morning taking a meticulous social history from a new client. The client, a man in his 20s, was pleasant and helpful. He seemed to genuinely want the assistance of the agency and to like Jorge. Two more interviews followed to set up services, and the man signed a release of information form for Jorge to meet with the cli- ent’s physician. Jorge cannot understand why this man never mentioned the fact that he is HIV+. This Jorge found out in the conference with the man’s physi- cian some weeks later. “How do these people think I am going to help them if they don’t tell the whole story?” Jorge fumed. “They come in here and want my help and then withhold information from me. They leave me in the dark. I don’t know what’s going on, and then they think I’m going to be able to help them.”

9. A new worker, Jill, is working at a large residential facility for the mentally ill and has been assigned four clients for whom she is to develop goals and objectives to help these clients move forward to greater independence. She meets with the first two clients and then confides to a worker who has been there longer that she had trouble understanding what the clients wanted to work on. The worker tells Jill, “Just make up the plans. These people are a waste of time. They won’t ever get any better. Look at that one. This is his fourth trip through here. No one ever made a difference with a plan, and you won’t either. Just put something down to satisfy the insurance company, and come in here with us. There is a good movie on TV tonight, and the staff is going to put the residents to bed early and get together in the patient lounge to watch it.”

10. Beatrice, who has suffered from schizophrenia for most of her life, has been placed in a long-term residential facility. One night the worker decides to take the residents to a movie. The residents all get in the van to go to the movies, and the worker waits to leave until everyone has a seat and has fastened their seat belts. Beatrice finds a seat but complains that the seat belt does not fit, that she cannot fasten it around herself. The worker replies, “Well, if you didn’t eat so much, you wouldn’t be so fat. You always pig out at the table, and this is what you get. I guess you’re too fat to go to the movies tonight, Beatrice. Guess you’ll have to just stay home.”

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Chapter 2 Ethics and Other Professional Responsibilities 75

11. Pedro noticed that his colleague, Antoine, was using clients’ spending money to make small purchases for himself. Each resident in the group home was given a specific amount of spending money every month, and it was kept in the resident’s envelope. When money was spent from the envelope, a receipt was to be left in the envelope showing where the money went. Antoine was taking money for small purchases for himself—lunch, movie tickets, a gold chain. He was placing the receipts for these purchases in the residents’ envelopes. It was not possible for administration, when doing an audit of all the residents’ accounts at the end of the month, to determine from the receipt who actually benefited from the expenditure. Pedro thought about telling the administration but felt it was likely that Antoine would deny the allegations, and this would ruin their working relationship. Therefore, Pedro did nothing.

12. Marcella began to drink in the evenings after work when her husband left her for another woman. As the months went by, the divorce became increasingly acrimo- nious. There were accusations, attempts to take Marcella’s money, and attempts to deprive her of custody of the children. The children began to exhibit problems, and there were financial problems as well. Drinking in the evenings expanded to a drink with lunch and later to a drink and then several drinks in mid-afternoon. In time, Marcella could not face the day without alcohol when she first got up. She continued to report for work where she was the sole worker on the day shift in a small residential setting with four clients. Marcella began to ignore the residents. It started with naps in the afternoon, which left the people unsupervised. Later, Marcella found it too hard to fix dinner for her residents and began to allow them to eat junk food for dinner. As the situation deteriorated, Marcella became more and more mired in self-pity, anger at her ex- husband, and alcohol abuse. She continued to work at the group home.

13. Arnie has problems with substance abuse. He considers himself an “alcoholic who likes a little cocaine now and then.” He is funny, articulate, and clever. When he comes to the case management unit he seems open about his progress and regressions. He always asks how his case manager is doing, what she did for Christmas, how her little boy is doing. Sometimes he brings in the paper and leaves it for her to read, saying he has read it and is finished with it. On Friday evening some of the case managers go out to dinner at a place that serves alcohol and very good food. They are having a good time unwinding after work when Arnie joins them. It appears that he is drinking a soft drink, but no one knows that for sure. Arnie and the case managers laugh and talk about their work until late in the evening. Arnie is funny and has hilarious insights about some of the clients he has encountered in the waiting room.

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76 Section 1 Foundations for Best Practice in Case Management

Exercises III: Decide on the Best Course of Action

Instructions: Sit with a small group of other students and decide how you will handle this situation. There are many areas both ethically and legally that are not clear, so the discussion you have with your colleagues is much like a discussion you might have in a real agency. There are no “correct answers.”

You have been working with a client who is HIV+ and is a regular user of heroin. He needs both medical and substance abuse treatment. However, he is inconsis- tent about coming for regular treatment and medical care. You suspect he is not tak- ing medications prescribed for him. In addition, he is sexually active with several women. He has asked that you not contact him at his home where he lives with one of his girlfriends. He has stipulated that no family members may have any in- formation about him. You think that if you could commit him to a substance abuse treatment facility he will be out of circulation sexually and he will receive the treat- ments he needs to save his life. You do not know for sure where he is but know his girlfriend with whom he has been living probably does. Can you contact her? What ethical and legal principles are at play here? What do you decide to do or not do?

Exercises IV: What is Wrong Here?

Instructions: Sit with a small group of other students and decide where there was a lapse in good judgment or a lapse in good ethical behavior. Where are the gray areas? What makes these situations clear-cut or unclear about the proper course of action?

1. A children’s case manager writes a letter to a parent of a 14-year-old girl, currently a client at the case management unit. In the letter is this: “While it has not been confirmed or established that your daughter was sexually abused, it is my opinion that she has experienced sexual abuse in the past.” What did this case manager do wrong? What could be the consequences to the family members if such a letter was received?

2. A human service worker is asked to plan a recreational activity for elderly residents on the floor where she works. She is not sure what to arrange but finally decides to do a program on supplemental Medicare insurance. She invites a friend who sells supplemental Medicare insurance. The friend gives a complete explanation, handing out brochures on her business and her business card and explaining the insurance products her company can offer individuals on Medicare. What is the issue here?

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Chapter 3 Applying the Ecological Model 77

Applying the Ecological Model: A Theoretical Foundation for Human Services

Introduction

In working with other people, human service professionals apply the ecological model to develop a broad understanding of the individuals who seek help. This model, sometimes referred to as person-in-situation or person-in-environment, looks at the indi- vidual person in the person’s context.

Ecology is a term that comes from biology and refers to organisms and their reciprocal relationships within their environment. In other words, biologists look at the organism and focus on the interactions of that organism with the surrounding environment. This clarifies and defines for biologists the organism being studied. Biologists see interactions among various organisms in an environment as keeping things in balance in that particular setting.

In seeking to find a model for understanding people within their context or within their environment, social work and other behavioral health professions began to use the lessons of biology to formulate a clearer picture of their clients. The eco- logical model employed in biology was found to be a useful way to better understand individuals, families, and other groups seeking assistance. Adopting this model in the 1970s, social service professionals have refined and improved the model so that today this has become a practical assessment tool for use in the social services. The idea is that each interaction affects in some way the people involved in the interaction and the way these interactions affect people determines how they will respond. One of

C h A p t E r 3

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78 Section 1 Foundations for Best practice in Case Management

the best ways to understand this is the way Greif and Lynch (1983, p. 38) describe what happens.

“(A)s a person enters each new situation he or she usually adapts to its demands and, by his or her presence, changes the situation at least struc- turally. A person is constantly creating, restructuring and adapting to the environment even as the environment affects the person.”

For example, an irritable older person living with her harried daughter who works full-time and is raising two children alone will be treated differently than an irritable older person living with her retired daughter and son-in-law who can afford to hire people to help them with their mother’s care. In the first example, the daughter is likely to become short-tempered with her mother. The children are likely to come first. Mother may conclude that her daughter doesn’t care about her. Mother’s hurt feelings are expressed by withdrawing from the family and expressing some resent- ment toward the children. The children, for their part, believe their grandmother doesn’t care about them because she rarely interacts with them and seems to resent them. Daughter herself is overworked and expects her mother to do things for herself the mother may no longer be able to accomplish. When this doesn’t happen daughter becomes irritated with her mother because she can’t afford to hire anyone to help her with her mother’s needs. In this situation everyone is exasperated with everyone else. We can see that the interactions each person has with every other person in this family seem to contribute to the exasperation and misunderstandings.

There are a number of ways a case manager might intervene to modify the envi- ronment to make the family system work better. For instance, you might find in-home assistance paid for with Medicare for the older woman. You might begin to encourage the daughter to take her mother to school functions and you would look for other opportunities for the children to have more positive interactions with their grand- mother. You might make a referral to a therapist for one or two sessions just to ex- plore how they might all understand and work together better as a family. However, if you just hear from the harried and resentful mother or you only see the disappointed and somewhat depressed grandmother you would not see the whole picture and you could not entirely address the problem.

In the second example the interactions will be different. The daughter and son- in-law share the responsibility and have help when they need a respite. They are not working and do not feel harried or overburdened.

If we look at the two daughters, there may be further differences in what each of them brings to their situations. Perhaps the first daughter who already feels overbur- dened never had a good relationship with her mother or blames her mother for some of her current troubles. How differently she will respond to her mother when com- pared to the second daughter who may have had a good relationship with her mother, sees her mother’s irritableness as simply a part of her not feeling well, and tends to humor her while making every attempt to make her mother comfortable.

What we learn from using the ecological model is that people do not just show up with a collection of problems. They live and work in an environment or a context as a unique person and that context can have positive or negative effects on their actions and those actions can affect others within the context positively or negatively.

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Chapter 3 Applying the Ecological Model 79

The Three Levels of the Ecological Model

The Ecological Model, Figure 3.1, looks at the person and the person’s context on three specific levels:

1. Micro level, where the focus is on the client’s personality, motivation, affect, and other personal attributes and how these affect the way he or she interacts with others, how others are perceived, and how these characteristics contribute to well-being or instability.

2. Meso level, where the focus is on the context immediately surrounding the per- son (family, church group, close friends, and work group) and how this contrib- utes to problems or provides support and solutions. Here we are seeking to know how the immediate environment enhances or impedes successful functioning.

3. Macro level, where the focus is on the larger society’s characteristics and the way the person experiences these or the way these are brought to bear on the person’s situation. Here we are looking at institutions and organizations within the broader society, such as the political system, social stratification, racism, the educational system, and the economy.

Human service workers are expected to be aware of all three levels when as- sessing a person’s situation and to be able to intervene on all three levels when such intervention is appropriate.

FIgurE 3.1 the three Levels of the Ecological Model

MACRO LEVEL

MACRO LEVEL

MICRO LEVEL

MICRO LEVEL

PERSON

MESO LEVEL

MESO LEVEL

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Digital Download Download from CengageBrain.com

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80 Section 1 Foundations for Best practice in Case Management

The Micro Level: Looking at What the Person Brings

When you do an assessment to open a case or do follow-up planning, a number of individual characteristics will impinge on the problems and the eventual outcome.

These micro-level characteristics can be divided into two broad categories:

Biological Characteristics Psychological Characteristics

Neurological development Early shaping experiences Reflexes Perception Genetic makeup Personality Degenerative processes Affect Illness (chronic, terminal, or temporary) Cognition Physical health Nurturance Nutrition Life transitions/current position in

the life cycle Motivation

This general outline gives you a starting point for understanding what your client has brought to the situation.

People have had different early life experiences, are composed of different genetic configurations, and possess different personalities and perceptions. Each of these differences interacts with the external circumstances of the person’s situation to promote self-fulfillment and well-being, to block those goals, or, quite possibly, to have no effect at all.

Looking at What the Context Brings

People function in contexts that are personal to them and they function in a larger social context, which is the larger society. These contexts can be divided into two broad categories:

Mezzo/Meso Level or Personal Context

Macro Level or Social Context

Family The larger culture of the society Work group The larger organization of the

church or workplaceSocial groups Family culture The larger community Family values Government Family structure Economy Religious group Social stratification Social class Prejudice and discrimination Role status, conflict, and strain Political system

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Chapter 3 Applying the Ecological Model 81

It is important to obtain information about the contexts in which people grew up and in which they are now functioning. The reason for the individual’s problems may lie in the context rather than with the person.

When you learn about the context, you learn more about what motivates your clients, the environmental cues they receive to behave or make decisions the way they do, and what early circumstances shaped their way of responding to their com- munity and their situation. People come from different social contexts. People grew up in different households with different parents and different levels of nutrition and encouragement. People have different ways of looking at things and explaining them. The environment in which they function may place pressure on them to see things in a certain way or to believe certain things about their environments and these may create problems for them in the larger society. The economy may have favored their work or begun to dispense with it. The political system may have awarded your cli- ent’s subgroup power or disenfranchised that group in some way. Your client may have experienced prejudice, an indifferent medical system, or a poor educational system. On the other hand, this person may have grown up in a wealthy suburb, attended pri- vate schools, and received the best medical care money could purchase.

Why Context Is Important

You are well aware of how distorted communication can become when a statement is quoted out of context. It is possible to skew impressions and deliberately create mis- understandings by quoting only a portion of what someone has said and not the entire conversation.

In a class discussion centered around self-exploration and self-awareness, for in- stance, Matt’s teacher questioned him about his homework assignment when he said he was not sure if he could help people with a certain disability. He went on to ex- plain that at one time it was thought that he had that particular disability, and he had worked very hard to prove that he was not disabled and to overcome people’s initial impressions of him. Now he found himself feeling uncomfortable with people who suffered from that disability. He also explained that he expected his course of study to help him overcome the problem and that he was very aware that his reactions might be inappropriate.

Later Anne, who was in class that day, confided to Aisha and Alice that she did not feel that Matt should be allowed to continue with his studies. Surprised, Aisha asked Anne why she felt that way. “Oh, because he said in class the other day that he feels uncomfortable around certain disabled people. I mean, if you can’t work with disabled people, you need to find something else to do.” Aisha and Alice quickly agreed.

Anne’s description of what Matt had said was distorted because only a portion of Matt’s comments were repeated outside the context in which they were said. She did not include the fact that students were having a frank discussion to better under- stand themselves. That same kind of distortion takes place when we look at individu- als out of context. In your work, every person you will see functions in a context, an

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82 Section 1 Foundations for Best practice in Case Management

environment. You cannot adequately understand that person without also being able to understand the context in which that person functions and interacts.

Urie Bronfenner (1979) described the mesosystem this way: “(A) mesosystem comprises interrelations among two or more settings in which the developing person actively participates” (p. 25). In other words, you are looking at where people function on a daily basis, the groups with which they interact daily and how those affect or do not affect their reasons for seeking help.

It is very tempting to overlook context. Many of us fall into the trap of thinking that A causes B: “Juan is irresponsible, so he lost his job.” If we eliminate A, B will cease to be a problem. If we make Juan more responsible, he will not lose any more jobs. Or “Jane is too demanding, so her husband left her.” If we teach Jane better in- terpersonal skills, she will have better relationships. Although helping Juan to become more job-ready and helping Jane to communicate better may very well be a positive part of your plan for them, this kind of understanding of their problems and assigning of solutions largely ignores the context in which these problems arose. It also makes it much easier to see the individuals as being entirely responsible or to blame for the problems they have brought to your attention. When we blame others, we nearly always feel less empathy with their difficulties, and we are less inclined to be truly useful in the human service sense.

However, supposing that we send Juan to job readiness classes and send him out newly prepared to get a job and we find that the work he does, basic plumbing, has limited opportunities and those who do hire discriminate against recent immigrants. In fact, Juan did not show up at his last job after being harassed by his fellow employ- ees and given only the most menial tasks. The employer complained that Juan was irresponsible but the employer’s refusal to stop the harassment and his occasional par- ticipation in it made Juan’s seeming irresponsibility somewhat understandable. Juan was responding to the prejudice exhibited toward him. There are other environmen- tal considerations. Suppose Juan comes from a family that does not value work and discourages him from being consistent on the job, finding other things they want him to do for them instead. Maybe the plumbing company really had very little work for Juan and he drifted away when he had time on his hands and became bored. The job complained because he wasn’t there when they needed him but they didn’t really need him very often. If we fail to look at the context, we fail to see the whole picture. Juan may be more responsible after his training but still facing the same issues in his environment he faced before. In working out his plan, we would want to see if there are ways to address these.

Seeking a Balanced View of the Client

All individuals constantly interact with any number of systems in their environments. All individuals bring to those interactions unique characteristics. Unless the human service worker has a balanced view of both the person and the person’s context, im- portant information and constructive opportunities are lost. In the cases of Ralph and Eduardo, we can see how important this is.

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Chapter 3 Applying the Ecological Model 83

Ralph went to prison because of some youthful gang activity. While he was there, he took advantage of every opportunity to change. He went to church regularly, devel- oped a personal relationship with a minister who came to the prison often, and obtained his high school diploma. Ralph was a warm, humorous person who attracted many friends. His outgoing personality attracted people to him who ultimately encouraged him and gave him support. During his time in prison, his mother wrote to him often, pleading with him to change his ways. Ralph felt bad about the trouble he had caused his mother, particularly in view of the fact that she had raised him after his father left home, and he saw her letters as a reason to do better. When he left prison, he enrolled in college courses and attached himself to the church, where he was warmly welcomed.

Eduardo, too, was in the same prison because of youthful gang activities. He was quiet and retiring and did not attract the attention and support that Ralph had secured for himself. Eduardo attempted to get his high school diploma while in prison, but he had trouble asking for academic help when he needed it and eventually abandoned the project in frustration. Preferring not to join groups, he did not go to church or any other group activity that promoted independence and responsibility. Because Eduardo spoke so little and rarely smiled, he was often misunderstood and thought of as being hostile. In fact, he felt shy and awkward around other people. Eduardo’s mother wrote to him regularly, and she too pleaded with him to do better and “turn his life around,” but Edu- ardo tended to see these letters as nagging and to blame his mother for the fact that his father left when he was very young. He rarely answered her mail. When Eduardo left prison, he moved back with his old friends and resumed his former criminal activities.

This illustration demonstrates how individual characteristics, that is, the micro level of the ecological model, play a role in the outcome for the client. Part of develop- ing a balanced understanding of the client is being able to see what the person brings to the situation and how that interacts with the larger context of the client’s life. Ralph brought a personality that attracted others to assist him. He brought a good relationship with his mother and a motivation to do things more constructively. Eduardo brought a more retiring personality, one that was less attractive to others and often misunder- stood. Eduardo’s interpersonal skills were not as developed as Ralph’s. The individual characteristics of Eduardo and Ralph affected the outcome of their prison time.

Now we will look at Eduardo and Ralph differently. We will look at the meso level of the ecological model, the level that immediately surrounds the person. For our purposes, let us suppose that Ralph and Eduardo are both warm, humorous people. Both make friends easily and enjoy the company of other people. Each of them is sent to prison for youthful gang activities, but the context is different. Eduardo goes to a recently built prison upstate that focuses on rehabilitation. There he is provided with high school and college classes as well as religious and self-improvement activities. He is able to take advantage of many different programs to further his goals. A supportive counselor meets with him on a weekly basis and works with him to create a good set of goals and implement them. The location of the prison has another advantage. Eduardo is now closer to his father, who lives only a few miles from the prison. His father begins to visit, offering his support and a place for Eduardo to live when his sentence is completed. Eduardo leaves the prison on a solid footing and continues his work toward a college degree.

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84 Section 1 Foundations for Best practice in Case Management

Ralph, on the other hand, is sent to an ordinary prison where the counseling staff is overwhelmed. His counselor sees Ralph’s potential but has difficulty enrolling Ralph in high school courses because they are crowded. During the time Ralph is at the prison, the education staff experiences a number of turnovers and layoffs. Ralph never can get into the program and stick with it. He rarely sees his counselor because of the num- ber of inmates with whom the counselor must work. No family member comes to visit Ralph, partly because he has been sent so far from where they live, and partly because they blame him for his incarceration and have lost interest in him. Ralph’s mother, sick with severe chronic asthma, rarely writes. Ralph attends church services at the prison regularly, but the prison does not allow inmates to meet with the pastors before or after services because of a strict schedule. The pastors who have formed relationships with some inmates visit irregularly at other times. When Ralph leaves the prison, he has not completed his high school diploma. He moves near some people he knew in prison, and soon he takes up the criminal activities in which he participated before his incarceration.

Here it is the context on the meso level that is different. Eduardo finds himself in a supportive context: a counselor who focuses on his goals and sees that these are implemented, plenty of self-improvement opportunities, a warm relationship with his father, and a prison committed to education. Ralph, however, finds himself confronted with indifference, lack of supportive programs and activities, an overwhelmed coun- selor, and a family too distant to give encouragement.

The interaction never ceases. The individual makes choices, but the environment prompts those choices. The individual responds to the outcome of those choices, and the environment reacts or adapts to that response. This interaction begins at birth. A fussy baby with calm, patient parents will start life differently from a fussy baby with overworked, anx- ious parents. An infant with severe disabilities will receive a good start with a large, loving family who has the money to devote their time and energy to getting her the best medi- cal and rehabilitative care. An infant with severe disabilities may arrive in another family where everyone tries their best to give the infant a good start; nevertheless, the disabilities prove overwhelming to the caretakers, there is no cure, and family members find that any semblance of a normal home life or time with other siblings is severely curtailed. The first baby is raised at home; the second one is placed in a good institution.

In human services, the trained eye will look for and see a balanced view of cli- ents and their contexts when assessing individuals’ needs. Just as important is the human service worker’s understanding of how person and context interact to produce certain outcomes for the client.

This topic is discussed in greater detail in Chapter 16 on assessment; this discus- sion puts forth the framework you will follow in assessing the individual’s contribu- tion to the situation and their current context.

We will turn here to Jane, the person who seemed too demanding so her husband left her. Here is what Jane brought to her difficult relationship with her husband that ultimately led them to separate. Jane was sharp witted but often biting and critical (personality). She expected perfection from both herself and her husband and never failed to point out his mistakes. She had a somewhat flattened affect, never seeming to be happy or engaged (affect). Jill suffered from chronic asthma (chronic illness). She brought memories of having been sexually abused by her two uncles at around age 11 (early shaping experiences). Her way of relating to men was characterized by

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Chapter 3 Applying the Ecological Model 85

cynicism and sometimes denigration. They were never good enough. She perceived men as being more interested in sex than in her (perceptions). She was highly moti- vated to get ahead in her career and her long hours of dedicated work protected her from having to be in close proximity to her husband for long periods. In other words, she used work to retreat and to protect herself (motivations). Here we see some of the personal characteristics Jane introduced into her situations. This is the micro-level understanding of Jane.

Turning once again to Jane, let’s look at her personal context or mezzo level. Here we would be looking at the groups or the environment immediately surround- ing her. She grew up in a family that valued work and education. They were never en- tirely aware of the extent of the uncle’s sexual abuse of Jane, although several times Jane’s mother warned the uncles to stay away from Jane. The family was undemon- strative and seemed to be always busy. They expected that of Jane. She was often chastised for minor imperfections and worked constantly as a child to be perfect and gain the admiration of her parents. Consequently, Jill married a person who was well educated and had a demanding job. Between the two of them it was hard for them to find time to be together. Jane’s husband, however, worked to make time, while Jane sought to avoid too much time together. Jane, mirroring the behavior of her family of origin, was extremely critical and demanding of her husband. Here we have looked briefly at Jane’s family of origin and the family she created with her husband.

Jane’s work group was equally striving and worked long hours with her. In many ways they supported each other and had more contact with each other than they did with their spouses. Further, Jane was rewarded with raises, outstanding evaluations, and public acclimations for her work. These rewards made work attractive to Jane.

However, Jane experienced role conflict, frequently feeling guilty about not be- ing an attentive wife when she was at work and feeling anxious about her work when she was at home.

Jane and her husband came from a middle-class background that valued educa- tion, hard work, and independence. They lived in a comfortable home in a suburb with two cars, friendly neighbors, and wide grassy lawns. Jill did participate in the annual block party each summer.

This is the personal context within which Jane functioned on a daily basis. What about the social context or macro level? Here we are looking at the society at large. Jane and her husband were solidly middleclass and lived that lifestyle. In addition, they were Caucasian and did not experience racial discrimination. Jane was paid less than her male coworkers who were doing the same job, experiencing gender bias, but for many years she was not aware of this disparity. The economy worked for the two of them as they held professional degrees for which there was a demand and found work readily after college.

In this case the larger social context barely impinged on Jane and her husband. That would not have been the case had Jane been a person of color, a person belonging to a large religious group that felt a woman’s place is in the home, or a person with a sig- nificant disability. The social context would have played a decisive role had Jane lived in a community that confined people of color to specific neighborhoods with fewer com- munity services. The social context would have come into play with regard to the laws related to gender and racial bias and social context would have become important if the economy had no jobs for people with Jane’s education and background.

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86 Section 1 Foundations for Best practice in Case Management

Developmental Transitions

The ecological model is also concerned with normal life changes, often referred to as transitions. These changes are called transitions because they are events that move a person from one phase of life to another, requiring the person to make adjustments or to adapt in some way to new circumstances. Many of these events are simply part of the normal development that all people experience from birth to death. These transitions are often expected, and for some transitions there is preparation.

Urie Bronfenbrenner (1979, p. 26) explains it this way, “An ecological transition occurs whenever a person’s position in the ecological environment is altered as the result of a change in role, setting, or both.” For example, Mrs. Stilmyer goes from being a wife to being a widow. Mr. Hoffman goes from being at home to living in an assisted living facility. The Carters go from being a couple without children to par- ents of twins. Sally goes from being at home with mother to spending half of every day in preschool. Joanne goes from married to divorced, with a new home and a big mortgage she must pay herself. Each of these is a fairly normal transition.

Some people do not cope as well with the changes brought by transitions as oth- ers do. Perhaps they have more going on in their lives than they feel they can handle. Perhaps the events have changed their lives dramatically in ways that are viewed as negative. Many of the people we see in the human service field are going through, or have recently experienced, one or more transitions. Here is a list of some of the transi- tions that people experience:

Starting kindergarten or first grade Starting a new job Going to high school Getting married Going out on the first date Buying a first home Leaving home for the first time Experiencing ill health Losing one’s job Losing a spouse through death Experiencing a disaster Divorce A large mortgage or other debt Losing some physical capacity Considerable financial losses Considerable financial gains Children leaving home Children marrying Birth of grandchild Death of a child

And there are many more. Although every single one of these events probably will not happen to one person, we can expect that most people, in the course of a long life, will experience a number of the transitions on this list.

It is important to know about the common life stages a person passes through and to recognize where your clients are in their life stages and transitions. Transition problems are common to many people. Often treatment is unnecessary—self-help and support groups can provide the support a person needs to make the transition. Sometimes, however, a person may find the changes overwhelming, completely nega- tive, or intolerable. These people may need professional help to handle these changes and adjustments.

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Chapter 3 Applying the Ecological Model 87

Developing the Interventions

You have looked carefully at your clients’ issues and problems. You have come to un- derstand the ways in which your clients have responded to their context and the way the context has contributed to your clients’ motivations and decisions. As a case man- ager, your role is to design a plan with each person that will address the areas of need. Human service workers can and do intervene on several levels.

Many clients of the social welfare system appear to be individuals who have encoun- tered inadequate support in their environment. One or more of the institutions that we believe should support the individual in our society has failed these people or has been un- able to supply what was necessary to avoid problems. Institutions such as education, medi- cine, the economy, politics, and the family may have let this person down in some way.

When this occurs, our society looks to the social welfare system to supply what is needed, to address the unfortunate gaps in a person’s life, and to apply interventions that will prevent a worsening of the problems. Your task as case manager is to look at the client and the client’s environment, to gather the facts about each of these, and to understand how context and person interact to the detriment of the person or contrib- ute to the well-being of the client.

With this information, a plan is developed with the person that addresses mal- adaptive interactions between the individual and the environment and that notes those parts of the environment that are positive and usefully supportive. The inter- ventions you design or choose should be two-pronged: personal interventions that strengthen the person to handle the environment, and environmental interventions that alter the context to better accommodate the person. Here are some examples of the types of interventions that can be incorporated into individual plans:

Interventions to Strengthen the Person

Interventions to Strengthen the Environment

1. AA for substance abuse Family education to support sobriety 2. Parent skills training for the

parents of a child they abused Group therapy for abused child

Temporary removal from home to foster care Foster home parents given information

on creating supportive foster home environment

3. Job training for the person with developmental disability

Work with the employer to provide a supportive work environment

4. Interpersonal skills training for adolescent in minor trouble

Use the child’s interests to develop more constructive in-school activities

Bring father into the picture in a positive way Family therapy with the mother

5. Medication for the person with schizophrenia

Regular appointments with psychiatrist

Place in a supportive living environment in the community

Develop constructive connections with the local church

Two family sessions to reinvolve the family in the person’s life

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88 Section 1 Foundations for Best practice in Case Management

These are fairly routine interventions in a person’s problems to ameliorate a neg- ative or destructive situation or to enhance the person’s self-fulfillment. The point is, however, that a service plan formed without the understanding that interventions take place in two distinct areas could be quite hapless and without focus. When doing a service plan, the human service worker makes certain that both areas have been ad- dressed with appropriate interventions wherever possible and that the interventions are documented in the record.

Working with the generalist Approach

The ability to recognize and effectively address issues on all three levels is generally referred to as the generalist approach. Aware that problems occur between the designated client—be that a family, an individual, or a group—and the client’s environment, it is important to see the interaction between the two and to look for ways to intervene on all the relevant levels on behalf of your client. As noted previously, clients are affected by the environment they occupy, and the environment is affected by the clients’ re- sponse. For example, look at how Ralph affected the people around him, their response to him and his response in return. Contrast that with Eduardo’s environment and the response he received as a result of his interactions with his environment. The client af- fects the environment and the environment affects the client in a never-ending interac- tion that can have positive and empowering results for the client, or just the opposite.

When case managers look at how people and systems affect the client’s prob- lems on each of the three levels, the case manager has correctly made a multilevel assessment. This assessment should lead case managers to develop interventions that will enhance both the identified client and the client’s environment. The generalist approach has as its goal the better functioning and increased competence of all par- ties. By looking at the whole picture instead of just a piece of the picture comprising only the identified client, the case manager has laid the foundation for making solid and long-lasting change possible.

Macro Level Interventions Are Advocacy

It is assumed that the human service worker is not limited to just helping individu- als. Your work as a human service professional places you in a unique position to be able to speak to the problems affecting large numbers of people. This happens in two ways.

In the course of your work, you will encounter many who have been damaged by abuse or discrimination. You will see groups of people harmed by poor school systems, a lack of medical care, or scant supervision. Ethically, we have an obligation to speak to the needs of those with less advantage in our society. Having seen the damage first- hand, we are better able to speak to conditions that need to be remedied in our larger society and to keep statistics and information on the extent of the problem for use in persuading lawmakers and others in power to take action.

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Chapter 3 Applying the Ecological Model 89

You will also see areas of service that have been neglected or that require develop- ment. Perhaps there is a need for more supported living arrangements for those with mental illness in the community. It may be that mothers returning to work from welfare lack the means to dress appropriately for the job, need day care for their young children, or require transportation to get to job interviews. Who better than the human service professional to bring to the attention of those who develop programs the areas of service that are lacking in your immediate community? You and others can bring to light the unique needs of your community and help to develop much-needed services.

For example, you might have a 12-year-old client who needs an individualized education plan due to his learning disorders. As an advocate for this 12-year-old boy, you would approach the school or support the parents in approaching the school to obtain this specified plan for your client. Your goal would be to make the school sys- tem work better for this individual. Your intervention would be on the meso level.

Now suppose that you find that there are numerous others complaining that students with learning disabilities are being ignored within the entire school system. You have six individual clients about whom you have concerns that the school is not meeting their needs. In addition, your colleagues in your children’s case management unit are also citing cases where their clients are not getting the academic support they need.

If you all go together to the superintendent of schools and respectfully request a review of the procedures and give him information, you have intervened on the macro level. Now you are advocating for an entire population, many of whom are not clients of your agency. Perhaps the problem involves several school districts or involves schools all over the state and the intervention is with the state Department of Education or, if that is unsuccessful, the state legislature. This is a macro level intervention. You are advocating for a broad population seeking to make a macro system work better for individuals with specific needs.

Unger (2013) considers macro level advocacy and the resulting positive social change an ethical obligation for human service workers. He expresses concern that those in the social services will grow further and further from their obligation to create change that supports a broader diversity of needs. Instead, he contends that these same workers often feel more comfortable confronting individual needs on the micro and meso level, dealing with individual issues and problems without seeking changes that would benefit marginalized populations. Social service work “obligates (social service workers) to put into practice their commitment to broad social change” (Unger, 2013, p. 493).

ASSIgnMEnT

Talk to a human service professional in your community about what that person sees as an unmet need in the community. What one service would the professional like to see developed? What specific need would that service meet? What client population would that project address? How would this service or program enhance the environment for clients? How would this enhance the functioning of clients within their environment? How could the clients who need this service be mobilized to work on their own behalf?

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90 Section 1 Foundations for Best practice in Case Management

Summary

In this chapter, we have looked at a method for assessing your clients in three differ- ent dimensions. This method, often referred to as the ecological model, looks at the attributes people bring to their problems, as well as the contributing factors in clients’ immediate environments and in the larger societies in which they live and function. Using this model prevents us from blaming only the clients for the problems or see- ing the problem as residing in an individual rather than their environment and com- munity. In addition to recognizing all the factors that make up clients’ problems, this model also allows us to recognize the broader need for interventions and to develop interventions that address issues on all three levels.

Using the ecological model, you can now produce effective solutions to the prob- lems and the social issues brought to you in the course of your work. In this way, you serve your clients and your society in meaningful and useful ways.

Exercises

These exercises can also be filled out online at CengageBrain.com.

Exercises I: Looking at Florence’s Problem on Three Levels

Instructions: Look at Florence’s problem as she presented it to the case manager. Decide which parts of her problem are on the micro level, which parts are on the meso level, and which parts are on the macro level.

Florence came in to see a case manager in an agency that addresses child abuse and neglect. Recently her daughter Crystal was removed from the home because of complaints by neighbors that she was abusing the child. An investigation of the situ- ation by child-care workers indicated the abuse was severe. The discipline she was administering was discipline she had experienced and witnessed as a child from her own parents and her aunts and uncles who lived on farms near her family. Florence related that she was the oldest daughter, third in line of nine children, of a farm family of 12 people. Her parents worked hard from sun up until long after dark. Much of the housework was done by Florence and her aunt, who lived with them. Her mother was ill, often in her room in bed. Florence does not know what the illness was, but does not recall her mother ever seeing a doctor. She tells the case manager that she knows her mother and her aunt did not like her.

At 18, Florence ran away with Dave, who did mechanical work on cars. “He was my first and only boyfriend,” she explains, weeping. Florence and Dave never mar- ried, and they had one child, Crystal. Last April, Dave died in a car accident on the in- terstate. Florence cries as she describes that night and the way the police came to her trailer and how kind they were to her. She describes how alone she has felt ever since.

Florence receives welfare. She completed eighth grade before her father “yanked me out of school to do housework. Said it was no place for a girl. A girl didn’t need no schooling.” Florence had enjoyed school, mostly for the companionship of other

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Chapter 3 Applying the Ecological Model 91

girls. “I’m shy of people, you know. But at school I had friends.” Florence remembers school as hard, and she had trouble with subjects like math and science. “Mostly I sat there and worried about what would happen when I got home from school. It was always something: Mom was worse, I was in trouble, there was some big push to get in a harvest. I was glad when I quit.”

Leaving with Dave had alienated Florence from her family. “Dave used to say, ‘They’re just mad ’cause they can’t use you no more.’” For this reason, Florence has not seen her family since Dave’s funeral, and they have made no attempt to get in touch with her even though they are only a few miles apart. The welfare agency reports that their workers have rarely seen Florence and have not as yet offered her any services for going to work, although she is on a list of single mothers they would like to make job-ready. Child welfare tells you that they cannot return Crystal until Florence has had intensive parent training and supervised visits with her child. They also tell you that they found her home worn, but immaculate.

Florence confides that she is terrified of going to work, that she feels useless, and that she probably has little to offer on a “real job.” She also appears to be depressed, crying at intervals and hanging her head. Socially, she is isolated both because of Dave’s death and because her neighbors are fed up with her child-care practices. “The neighbors don’t like me either,” she says with resignation. The child-care agency is asking for parent training, but it is unclear who will offer that in this rural area.

What part of Florence’s problem is a micro-level problem?

What part of Florence’s problem is a mezzo-level problem?

What part of Florence’s problem is a macro-level problem?

Exercises II: Designing Three Levels of Intervention

Instructions: Look at the four cases below and decide how you would intervene on three levels: the personal (micro), the contextual or social context immediately surrounding the client (meso/mezzo), and the larger environment (macro).

1. Maria is paralyzed from the waist down following an accident three summers ago in a swimming pool. She is hoping to complete her degree in accounting, but she is complaining of depression and an inability to focus on school. When you see her, she looks anxious and tired. Her affect is flat, and she tells you nothing in- terests her. At the local college, she has had trouble finding appropriate parking and misses many days of class when the weather is bad because of the parking situation. One of the professors she must work with closely has made remarks

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92 Section 1 Foundations for Best practice in Case Management

about the difficulty of “other people getting around that wheelchair.” She be- lieves her boyfriend, who was with her the night the accident happened, has remained with her simply out of pity. When they fight about other things, she throws this up to him, although he vehemently denies it and tells Maria this is a hurtful accusation.

Interventions on the micro level:

Interventions on the mezzo level:

Interventions on the macro level:

2. Mr. Groff is 93 and living alone in his home. He only stopped driving last year. He would like to get out more, perhaps go to the senior citizen center. In addi- tion, he would like to go to the Lions Club and to participate in a foreign policy club he belonged to for years. He tells you sadly that the members of the foreign policy club always seemed amazed at the reading he had done and the sound opinions he expressed, “as though I should be senile!” Since he stopped driving, he has lost contact with them. Right now he sees no reason to go to a nursing home and feels that if he had transportation he could continue to buy his grocer- ies, prepare his meals, and care for himself generally. He tells you, however, that he would like to find a way to be less lonely.

Interventions on the micro level:

Interventions on the mezzo level:

Interventions on the macro level:

3. Margie is in a sheltered workshop for people with developmental disabilities. She does well at work and has many friends. She lives with her mother, and her mother is not happy with the new level of independence Margie is develop- ing. She often goes out with others from work and the supervisors for dinner on Friday night. She has joined a social group for individuals with disabilities much

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Chapter 3 Applying the Ecological Model 93

like hers, and they go bowling and to the movies. Margie has, since she went to the sheltered workshop, learned how to use the phone to make appointments with her doctor and dentist and how to ride the bus to and from both work and the social club, and she has been shopping to buy her own clothes twice with her case manager. Margie’s mother complains about all this. She tends to blame Margie for leaving her alone at night and making her unhappy. “Since your father died, you’re all I have,” she tells Margie. Margie’s response to this is to cry and stay home and give up some of her independence. Sometimes she has missed work, hoping to make her absences up to her mother.

Interventions on the micro level:

Interventions on the mezzo level:

Interventions on the macro level:

4. Chris is a single father who is trying to work and raise three small children. His wife was killed 2 years ago in a traffic accident. After the initial shock and out- pouring of support from friends and neighbors, Chris found himself alone with all the responsibilities and very unsure of himself. He would like to meet other men who have the same problems but cannot find any groups, even though he has been told about several men who are in the same situation. He tells you he is not sure what the best method is for disciplining his children, whom he describes as “good kids.” Sometimes he feels he is too lenient with them, and at other times he is afraid he is unnecessarily strict with them. A local women’s health center has groups for bereaved single parents, but Chris believes those would not be open to him. “It would be all women, wouldn’t it?” he asks. In addition, he is having a hard time at work balancing the responsibilities there with parenting responsi- bilities at home. “Of course, I want to do a good job and get the promotions so I can support these kids through college, but I need to be home in the evening, or someone does, and I don’t think that is always well received at work.”

Interventions on the micro level:

Interventions on the mezzo level:

Interventions on the macro level:

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Chapter 4 Cultural Competence 95

Cultural Competence*

Introduction

Seeing each of our clients as unique individuals is the only way to accurately perceive them and to be constructive in the way we serve them. One key element of individu- ality is culture and subculture.

Most of our attitudes and perceptions are the result of our interactions with oth- ers throughout our lives. In time, these interactions come to seem natural. As profes- sionals, we need to become aware of our personal ways of thinking about others and their situations. Is our thinking useful? Will it promote the well-being, self-esteem, and independence of our clients? Because we are a culturally diverse society, it is important for professionals in human services to respect differences and to seek to understand these differences whenever possible.

Culture and Communication

Each of us brings to any situation perceptions and attitudes that are influenced by our own culture. Our own ethnic group, family values, outstanding experiences, and cultural traditions all influence both the way we communicate to other people and what we believe other people mean when they communicate with us. Often, we are unaware of the extent to which these factors color our interactions with other people.

In addition, we do not usually take the time to understand that others may come from a culture that differs from our own significantly. We may judge others’ actions by the standards prevalent in our own culture. We may expect certain behavior we

C h a p t e r 4

* The material in this chapter is adapted with permission from Communicating with Strangers, 3rd ed., by W. Gudykunst et al. Copyright © 1997 McGraw-Hill Companies.

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96 Section 2 Useful Clarifications and attitudes

believe is appropriate and become annoyed when we do not see that behavior. We may misunderstand the communication of others, leading to lost rapport and oppor- tunities. This is dangerous when we have accepted the professional responsibility for giving assistance to other people.

Your Ethical Responsibility

Ethically, you have a responsibility to take the time and make the effort to become familiar with cultures that differ from your own that you have extensive contact with as a social service professional. It is not ethical to simply assume you know all there is to know about a group because you see members of that group on a daily basis or hear about them from the news media. Instead, you need to ask questions, take seminars, and gather information that will enhance your understanding of that group or culture.

When You Are Not Sure

It is not possible, on the other hand, to study and become familiar with all the differ- ent cultures you might encounter in the course of your professional lifetime. In your work, it is quite likely that you may encounter someone from another group whose culture is unfamiliar to you and whom you will see only briefly. What you need is a method you can use that will allow you to participate in those encounters and interac- tions competently.

Where Are the Differences?

Differences among people occur on a number of sociological levels. These differences can be overcome and understood, or they can become obstacles to good communica- tion and understanding.

Cultures

Generally, cultures coincide with national or political boundaries. People living in one country have a culture that differs from the culture of those living just across the bor- der. When we refer to culture, we are really talking about the culture assumed by an entire society.

This means that we in the United States have in common with one another a basic knowledge. We learned this knowledge through the socialization process—from our schools, parents, religions, and even television and magazines. Although each in- dividual may see the culture just a bit differently and no one knows everything there is to know about it, people share enough in common to be able to relate to and coop- erate with one another.

By the time we are young adults, the culture we carry with us in our heads is largely unconscious. Our culture influences how we communicate with other peo- ple, and it influences the way we determine what the other person means. In other

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Chapter 4 Cultural Competence 97

words, what we say is affected by our culture, and, in turn, our interpretation of what another person is saying to us is colored by our culture. Because this process has be- come automatic for us, we are not aware of the significant influence our culture has on our interactions with others. Furthermore, if most of the time we are communicat- ing with others from our own culture, we will assume that all people mean what we mean and see things as we see them. With this way of thinking firmly in place, there is a tendency to assume that our own culture is the better or correct way to be at any given time.

Subcultures

Within any given society, there are groups of individuals who, for the most part, follow the culture of their society but hold in common with each other somewhat different cultural ideas. This may be a religious group that holds ideas that are somewhat dif- ferent from mainstream thinking about patriotism and serving in the military. It might be an ethnic group whose subculture is shaped by the discrimination experienced in each generation.

Subcultures usually are not completely out of step with the larger society’s cul- ture. There is, however, something about the subgroup culture that sets its members apart. It might be values, traditions, beliefs, lifestyle, or any combination of these.

Race and Ethnic Group

Important in understanding subcultures is understanding the terms race and ethnic group. According to Gudykunst and Kim (1997, p. 20), race refers to a “group of people who are biologically similar,” and ethnic group refers to “a group of people who share a common cultural heritage usually based on a common national origin or language” (p. 20).

Racial groups often have distinguishing physical characteristics, whereas ethnic groups may be distinguished by their language, religion, or some other aspect of their culture. It is important to keep in mind that race alone is not a factor influencing communication; on the other hand, ethnicity with its culture can have considerable influence on communication. If the racial or ethnic group of your clients indicates a subculture that is unfamiliar to you, the potential for misunderstanding is increased.

How We Develop a We-versus-Them Attitude

During the process of socialization, we learn that some groups are acceptable and oth- ers are unacceptable. The acceptable groups are seen by us as in-groups. We are more comfortable with in-groups than with groups we consider unacceptable. We see the members as being similar to us, and we expect the members to hold beliefs and val- ues very much like our own, and to act and think as we would. When we talk about in-groups, we generally do so favorably, holding them in positive regard. We are better at predicting how members of in-groups will respond or behave.

Out-groups are those groups with whom we feel uncomfortable—groups with whom we have less inclination to interact on a regular basis. Generally, we do not hold members of out-groups in a particularly favorable light. We may be suspicious of the

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98 Section 2 Useful Clarifications and attitudes

motives of an out-group because we do not fully understand its culture. Using our own culture as the standard, we may find the out-group culture inferior. Members of the out-group may appear unpredictable, unreliable, or devious to us.

Strangers

When people do not act or think the way we believe they should, they seem strange to us. Many people you will encounter in the course of your work will seem like strangers to you. For example, Julio is a stranger to nearly everyone he sees on a daily basis. He, his little brother, and his mother live in a small city with others from Puerto Rico. When he is with his small group of friends and relatives, he is not perceived as strange. On the other hand, when he attempts to interact with the larger American culture, many see him as a stranger. His language, his behavior, and, in some cases, his attitudes appear strange to members of the larger culture. He is tolerated, and even given menial work, but he feels set apart. People he must meet and work with every day view him as a stranger because they know little about Julio’s culture. They see him every day, yet he is in no way considered part of their group.

Julio went to the case management unit to seek services for his brother, who was diagnosed by the school psychologist as having an intellectual disability. There he en- countered some problems. His accent and unfamiliarity with the language made it dif- ficult for him to be understood. While the worker talked about residential placement and education, Julio resisted, indicating the family just needed help with the local school, where he felt his brother had been misunderstood because of a language problem. The local school had suggested Julio and his mother go to the case management unit because school officials did not believe they could provide adequate services. Julio felt their refer- ral indicated insensitivity and an unwillingness to be concerned with keeping the family together and helping his brother function better in English. The vast array of services being offered at the case management unit was bewildering to Julio. He was inclined to simply withdraw from the situation and tell his mother to keep his brother at home.

To the worker at the case management unit, Julio seemed strange. She did not exactly use that word, but she wondered with some exasperation why he did not want to take advantage of the many services available to his brother. Why did he seem so reluctant to keep appointments with both the worker and the school? Why had he withdrawn his brother from school when this was clearly against the law for a child so young? To the case manager, Julio’s behavior was inexplicable.

It is always the majority group that defines who is a stranger and who is not. The people who seem strange to us are not strangers to those with whom they hold common cultural traditions. If the situation was reversed and we found ourselves in a place where our cultural ways and values were different from the majority, then we would be the strangers.

Gudykunst and Kim (1997) use the concept of the stranger to define those whom we encounter who seem strange to us, whose ways of thinking and acting are unfamil- iar, and who are not members of our in-groups. In other words, they are people who are close enough that we cannot ignore their presence, but they are unfamiliar to us

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Chapter 4 Cultural Competence 99

and therefore seem like strangers. (Throughout this chapter, I use the term stranger as it is defined here.) If people come from another culture, possibly from another coun- try, it is entirely possible that they do not know enough about your culture to be able to relate easily to you. In addition, it is quite likely you do not have enough informa- tion about their culture to be able to make the new situation smoother for them.

As the human service professional, you are the person who can take the initia- tive in making the adjustment smoother for those who come to us as strangers. When people we might consider strangers have developed a good degree of competence in the majority culture and can communicate well, they will be healthier. Studies, how- ever, indicate that it takes a long time for immigrants to adjust to the new culture and that if this maladjustment is severe or long-term, it can cause serious mental health problems as a consequence.

As the world community becomes more global, we can expect to encounter peo- ple from many different cultures who will seem like strangers, people who are differ- ent. Gudykunst and Kim (1997) make the point that we have internalized our own culture to such a degree that we believe it is innate in some way. They write, “anyone whose behavior is not predictable or is peculiar in any way is strange, improper, irre- sponsible, or inferior” (p. 357).

When people deviate from the familiar, we are likely to notice it instantly. We may feel anxious or surprised and uncertain. We may be forced to look more closely at our own cultural assumptions. Perhaps we are forced to conclude that aspects of our culture that we have taken for granted are not particularly useful. Our cultural identity may be challenged. Obviously, it would be easier to avoid all this and stay away from strangers. Many people do just that, preferring not to experience these un- settling emotions. In human services, however, our work is all about encounters with people, and our purpose is to be helpful. Avoiding strangers would be irresponsible. For that reason, we need to know what to do when we encounter strangers.

Anxiety and Uncertainty

It is common for most people to feel uncertain or anxious when they are attempting to interact with people from other cultures. If we are consumed with our uncomfortable feelings, our communication with strangers will be impeded. We need to be able to manage our feelings during these encounters to provide for a constructive exchange.

Many times we attempt in some way to reduce anxiety or stress in these encoun- ters. We project our notions about what the person means, giving us a certainty that might not be justified. We might try to develop theories about the other person that feature similarities. The more we believe a person is like us, the less likely we are to feel anxious. Thus, we might look for similar psychological reactions, similar group af- filiations, and similar cultural aspects.

When Misaki came from Japan to study at a local college, she was the only per- son from Japan on campus. Other girls in her dorm invited her to join them for meals and to walk to classes with them, and Misaki did so. When the other girls laughed and talked about trivial matters, Misaki was silent. She rarely made small talk with the

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100 Section 2 Useful Clarifications and attitudes

girls. They began to interpret her behavior as “too serious” and worked even harder to draw her into their discussions. Misaki was always pleasant but contributed little to these exchanges.

To the girls in her dorm, she seemed too serious; but to the resident assistant, Misaki appeared depressed. Ann, the resident assistant, based her opinion on the fact that Misaki never looked up when she spoke and never looked directly at Ann. Ann asked Misaki if she would like help with her sadness or depression. Misaki said “yes,” so Ann made a referral to the campus clinic. There an intake worker decided that Mi- saki was indeed depressed and concluded it must be about leaving her homeland. To each question the intake worker asked, Misaki answered “yes.” Yes, it was hard being here in America; yes, she missed her parents; yes, she had trouble understanding ev- erything the professors said in class.

A counselor at the clinic recommended to Misaki that she join in more with the girls in her dorm and learn to “loosen up and have fun.” In Japan, however, people who talk a lot are not viewed as particularly trustworthy. Those who use silence more frequently are considered discreet and trustworthy.

The girls in the dorm, the resident assistant, the intake worker, and the counselor in the clinic did not understand Japanese culture well enough to refrain from judging her by the standards of their own culture. Furthermore, in Japan people often assess what it is the speaker wishes to hear and answer “yes” as a means of keeping social harmony. They might not mean yes in precisely the way an American might interpret it. In addition, Japanese people often do not look directly into the eyes of someone with whom they are conversing. To look directly at another is a sign of defiance or aggression. Looking away is a sign of respect. The Americans took Misaki’s behavior as an indica- tion of shyness or depression because that is what the behavior would most likely mean in American culture. By fitting Misaki’s behavior into American cultural meanings, the Americans did not have to feel anxious about how to interpret the behavior of a stranger.

American girls talk to each other frequently and often about trivial matters as a way of cementing their ties to one another. To the girls who befriended Misaki, this seemed normal. Her silence did not. In order not to feel anxious about her, they pro- jected their own theories about her behavior onto her and concluded that she was sad about leaving her home in Japan. This was a normal reaction, understandable from their standpoint. The theory made Misaki seem more like them; thus, their theorizing reduced their anxiety.

We will unwittingly go to great lengths to resolve our anxious or uncertain feelings. Often what we do is inaccurate and not useful in promoting clearer communication.

Thoughtless versus Thoughtful Communication

First, we need to find a way to control our anxious feelings to allow us to really be able to listen and communicate. If we are likely to feel anxiety when we talk to strangers and if this anxiety is going to interfere with a realistic understanding of these strangers, we are going to hear and communicate in a skewed or inaccurate manner. What is worse is

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Chapter 4 Cultural Competence 101

that we may be only vaguely aware of this problem. The following sections discuss areas you can evaluate to make your communication more thoughtful and accurate.

Recognizing Our Tendency to Categorize

Think about what we do when we are communicating without thought. We catego- rize people; we assume there is only one correct or normal way to view things; and we are closed to information that does not fit with our cultural perspective. When we encounter someone who is different, we dump that person into one of our large cat- egories or stereotypes. When someone’s behavior does not fit or that person’s think- ing is strange to us, we are thrown off balance. To prevent that, we have categories all ready into which we can place such people. Because we do this habitually, we are not completely aware of our categorizing.

Actually, as you work with various sorts of people, you may find that you need to add many new categories to your conceptualizations of others. These categories, if more spe- cific and definitive than those based on stereotypes, will be better predictors of behavior.

Looking for Exceptions

To become more thoughtful as you communicate, start to look carefully for the exceptions to your categories. If you think all Hispanics are loud, think about times when you have encountered Hispanic people who were not loud. If you believe all Muslims are militant, look for times when individual Muslims have expressed cooperation. If you believe all Jews horde money, seek out the times that Jewish people have been generous. In other words, recognize that the categories you have been using are likely to be much too broad to account for all the specific differences you may encounter in the people you serve.

Another way to look for exceptions to your categories is to seek differences in each specific individual. If you dismiss a stranger as coming from a group that is gen- erally believed to be resistive to your efforts to help, you will have little success com- pared to recognizing the resistance and then looking for times the stranger was not resistive. If you have categorized someone as too talkative, look for times when that person was listening instead. If you are sure the people in a particular group are stu- pid, look for times individuals in that group made wise decisions or choices. Seeing others as individuals will make these exceptions important to you. As a competent worker, you will diligently seek these exceptions to gain a more accurate understand- ing of the people you are serving.

Checking Our Attributions

Most research shows that when we see a stranger’s behavior as negative, we are inclined to blame that behavior on the stranger’s character or disposition. When we see the strang- er’s behavior as positive, we are more likely to think this person is an exception and attri- bute the exceptional behavior to the environment or the circumstances. In other words, it appears that for many of us, giving up our stereotypes is very hard. We would rather see the exceptions to our stereotypes as something external to the stranger, and we are likely to blame behavior that seems to fit the stereotype on the personality of the stranger.

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102 Section 2 Useful Clarifications and attitudes

The opposite is often true as we go about attributing causes to our own behav- ior and the behavior of those we consider to be members of our in-group. If we see negative behavior in these people, we are likely to blame the environment or circum- stances, while we often consider positive behavior a reflection of the person’s charac- ter. The following list summarizes how we often see things:

Our positive behavior Attributable to our good character Their positive behavior Attributable to the environment or the

circumstances Our negative behavior Attributable to the environment or the

circumstances Their negative behavior Attributable to their poor character

When we do this systematically, it reveals prejudice on our part. In addition, these systematic errors in attribution cannot have come about thoughtfully. They are thoughtless, automatic ways of looking at other people. As you become more thought- ful in your communication, become aware of how you explain the behavior of others.

Evaluating Scripts

We have all learned certain scripts for the activities we engage in frequently. For in- stance, if you meet someone you see often, but do not really know very well, you might say “Hi” as you pass that person. She might say, “Hi. How are you?” You would probably say something like, “Fine, and you?” She might then respond with “Just fine, thanks.” By the time this exchange is completed, you may be several yards apart and walking in opposite directions. This constitutes a script for passing someone you see every day but do not know very well.

There are scripts for a variety of everyday activities. We carry them in our heads to be used when the appropriate situation presents itself. We have learned them first by observation and then from our own participation in these activities. The exchange demonstrated in the previous paragraph did not take much thought. Two people may pass each other every day and go through much the same exchange. They do not stop and consider what to do as each encounter presents itself.

We expect that people from our culture will respond to our “hello” with a “hello” of their own. If one individual does something different, we are thrown off balance. People from other cultures, however, have learned different scripts. For instance, a common area of misunderstanding relates to the fact that different cultures have different nonverbal ways of indicating that they do not want to be approached. Suppose you are indicating through your body language to someone from another culture that you do not want to be approached, and this person approaches you anyway. You may feel pushed and invaded when, in reality, the stranger could not recognize the signals. You could make a similar mistake. You might see a person you want to join you. You might wave to the person and point to your group, indicating that the person should come over and join you. To a per- son from an Asian country, this would be insulting. Waving people over, and especially using one finger to do so, is considered rude. We are looking at two different scripts.

Behavior or communication that seems strange to you may simply be a different script presenting itself. Stop and think about what the unexpected behavior means to the

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Chapter 4 Cultural Competence 103

stranger. Is this offensive behavior, or does the stranger mean something quite different? Is there a possibility that you are misreading the signals or cannot recognize the signals from this stranger? Is it likely that the signals you are sending are not familiar to the stranger?

Checking Perceptions

Gudykunst and Kim (1997), who have written extensively on this subject, recom- mend that we simply check our perceptions with strangers to see if these perceptions are accurate. Instead of assuming that we know what a stranger means, we need to check. These authors recommend a three-step process:

1. Describe the other person’s behavior, being careful to simply describe what was observed without evaluating or labeling the behavior.

2. Tell the stranger how you interpreted the behavior. In doing so, be matter of fact. Refrain from any hint of a negative evaluation of the behavior.

3. Ask the stranger if your perceptions are accurate.

Checking your perceptions is a good way to keep the communication between you and the stranger accurate and meaningful. It is important not to assume you know what the stranger means or what the stranger feels. Check with that person to see if what you perceive is correct.

Allowing Differences

It cannot be stressed enough that thoughtful communication is extremely important in reaching real understanding with strangers. Obviously, the better the understand- ing between you and a stranger, the more likely it is that you will be effective and competent in your assistance to that person.

Not all strangers will respond the same way to their new environment. Differ- ences between the culture of the stranger and the culture of the host society may account for how a stranger responds. Large differences in verbal and nonverbal be- havior, in norms or language, or in political and religious orientation can make adapt- ing to the new surroundings more difficult. Where the differences are small, things may be easier for the newcomer. For example, someone from Canada would have less trouble adjusting to the United States than someone from Botswana. When you take this into account, you are able to look more thoughtfully at the stranger’s attempts to adapt and be more helpful in that process.

In addition, recognize that there is a lot you do not know and be open to finding out more. When you are communicating with someone who is a stranger to you, put aside your goal for that conversation and begin to listen carefully for new information the person might be providing to you.

Finally, accept that there is more than one way to view something or to under- stand something. People have different perspectives, but that does not mean that some are superior to others or more correct than others. We may have been taught that this is so, but look at other ways to explain behavior besides your own perspective. Try to understand what perspective the stranger may have. This can be done only if you communicate thoughtfully.

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104 Section 2 Useful Clarifications and attitudes

Dimensions of Culture

Researchers in the field of communication have looked for ways to help us under- stand cultural differences even when we do not know the details of every culture. They have proposed that cultures have an underlying foundation of individualism or a foundation of collectivism. Cultures fall along a continuum, with no single culture being all one or the other; but many researchers believe that communication can be facilitated between people of different cultures if we know whether the stranger with whom we are communicating is from a culture that is primarily an individualistic cul- ture or a collectivistic one. This tool is particularly helpful when we do not know all the particulars of a specific culture.

Individualistic and Collectivistic Cultures

Using information from Gudykunst and Kim (1997), we will look at some of the characteristics of cultures that are predominantly individualistic or collectivistic. Figure 4.1 summarizes some of the general differences between these two types of cultures. Figure 4.2 lists some examples of countries that tend to be individualistic and some that tend to be collectivistic.

Individualistic Cultures Collectivistic Cultures

Individual More Important Group More Important

• Individuals should look out for themselves and their families

• Promote self-fulfillment • Emphasize individual initiative and

achievement • T h e i n - g r o u p i n f l u e n c e i s v e r y

specific to times and place • Individual goals are emphasized • Tend to apply their value standards

to everybody (universalistic) • Emphasize needs and goals of the

individual over the group • Support unique individual beliefs

• Members of in-groups look out for each other in exchange for loyalty

• Require that people fit into the group • Emphasize belonging to groups • The in-group influence is very general

over all situations • Group goals are emphasized • Tend to apply different value standards

to members of their in-groups and to members of out-groups

• Emphasize the needs and goals of the group over the individual

• Shared in-group beliefs

Have a More Vertical Culture Have a More Horizontal Culture

• People are expected to stand out from others

• Value is placed on freedom • Maximizing of individual outcomes

• People are not expected to stand out from others

• Value is placed on equality • Cooperation with in-group members

Source: Adapted from Communicating with Strangers, 3rd edition, by W. Gudykunst et al, McGraw-Hill Companies.

FIgURE 4.1 Characteristics of individualistic and collectivistic cultures

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Chapter 4 Cultural Competence 105

How Individualistic and Collectivistic Cultures Differ

First, individualistic cultures tend to place a higher value on the individual than on the group. Collectivistic cultures, on the other hand, tend to place more value on the group. Another difference lies in the way in which society is viewed. In individual- istic cultures, there is ranking and hierarchy; collectivistic societies tend to be more egalitarian.

There is also a difference in the way the two cultural types use the surrounding context in communicating. In individualistic societies, the communication tends to be so direct that a person rarely needs to check the context to fully understand the mean- ing. In more collectivistic societies, context is extremely important. See Figure 4.3 for a summary of the communication differences between the two types of cultures.

Figure 4.4 highlights some of the specific elements that make communication different between individualistic and collectivistic cultures. As the comparisons in the figure indicate, there is plenty of room for misunderstanding. A person from a culture that values clear, explicit information might suspect someone from a high-context cul- ture of being manipulative or confused. Someone from a horizontal culture might find someone from a vertical culture rude and boorish or incredibly selfish. If a client from a collectivistic culture waited to engage in services until he had group consensus, the worker from an individualistic culture might mistakenly think the client was resisting treatment or uninterested in help. If a worker from an individualistic culture encour- aged a woman from a more collectivistic culture to look out for herself and leave an

Countries that tend to Be Individualistic Cultures

Countries that tend to Be Collectivistic Cultures

(based on predominant tendencies in the culture)

(based on predominant tendencies in the culture)

Australia Belgium Canada Denmark Finland France Germany Great Britain Ireland Italy Netherlands New Zealand Norway South Africa Sweden Switzerland United States

Brazil China Columbia Egypt Greece India Japan Kenya Korea Mexico Nigeria Pakistan Panama Peru Saudi Arabia Thailand Venezuela Vietnam

FIgURE 4.2 Individualistic and collectivistic cultures

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106 Section 2 Useful Clarifications and attitudes

abusive marriage, the client might feel helpless and unsupported. Leaving the group might not be an option for her.

One common error is for people from individualistic cultures to assume the per- son with whom they are speaking from a collectivistic culture is speaking as directly and explicitly as they are. Individuals from collectivistic cultures can make the re- verse mistake, assuming the person from an individualistic culture is only implying or speaking indirectly.

Privacy and Self-Disclosure At different times, we feel open to interaction with other people or we feel closed and seek privacy. Different cultures regulate privacy needs in different ways. While individualistic cultures do so with physical boundaries, collectivistic cultures do so by psychological means. For instance, in collectivistic so- cieties, people who might be encountered in general public situations are often seen and treated as nonpersons and simply ignored. In this way, the individual is protected from unwanted involvement. In individualistic societies, this would be seen as rude.

Time Time is conceptualized differently in different cultures. How people conceive of time determines how they are likely to use it as well.

Individualistic Cultures: Low-Context Communication

Collectivistic Cultures: high-Context Communication

• Low-context communication is more precise

• Direct and explicit

• High-context communication uses understatements, pauses, silences, or a shortage of information

• Indirect and implicit

Context Is Only Minimally Important Context Is Important in Determining Meaning

• Tend to use very direct communication

• Listener does not have to use con- text to obtain meaning

• Communication is less ambiguous • More concerned with clarity as nec-

essary for effective communication • Communication is about the same

for in-groups and out-groups • Value saying what you think • Value truthfulness • Verbally direct, precise, and absolute • “Yes” means agreement

• Tend to use more indirect communication • Listener must use context to obtain

meaning • Communication is more ambiguous • More concerned with avoiding hurting

others or imposing on others • Communication is very different for

in-groups and out-groups • Value avoiding confrontations • Value courtesy • Verbally indirect, imprecise, and

probabilistic • “Yes” does not necessarily mean

agreement

FIgURE 4.3 Communication differences between individualistic and collectivistic cultures

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Chapter 4 Cultural Competence 107

Individualistic Cultures Collectivistic Cultures

Privacy Regulation Privacy Regulation

• Use of physical barriers such as doors, walls, private rooms and offices, fences, hedges

• Use of psychological barriers such as speaking softly, treating one an- other with decorum, treating people in public as nonpersons, sending nonverbal cues that approach is not desired

Self-Disclosure Self-Disclosure

• More likely to self-disclose because privacy is protected through physical barriers

• Less likely to self-disclose to protect accessibility of others

Monochronic Time Polychronic Time

• Time is seen in discrete compartments

• Compartments are used to schedule events one after the other

• Actual time on the clock is more important

• Emphasize adherence to schedule • Punctuality important

• There are no compartments • Can do more than one activity at a

time • Activities are more important than the

time • Emphasize completion of tasks • Punctuality not so important

Face (public self-image) Face (public self-image)

• Less emphasis on respect for elders and superiors

• Concern with saving one’s own face

• Emphasis on respecting or giving face to one’s elders or superiors

• Concern with saving the other’s face

Persuasion Persuasion

• Focus on the person they are trying to persuade

• Direct requests for what is desired • Likely to threaten the person’s

security • Likely to state negative conse-

quences to a person if the person does not . . .

• May ingratiate themselves to the other (I really value you, therefore . . .)

• Focus on the context in which the persuasion is taking place

• May use altruistic strategies (for the sake of the group, company, etc.)

• Likely to appeal to duty, concern for the whole group

• More likely to promise positive conse- quences if a person does . . .

• May imply a “good” person would do this

Expression of Emotion Expression of Emotion

• Less concerned with using emotions to further group cohesion or harmony

• Display those emotions more likely to support group cooperation

• Display more of a variety of emotions • More likely to express positive emo-

tions with members of out-groups

FIgURE 4.4 Specific communication differences

(continued)

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108 Section 2 Useful Clarifications and attitudes

Face It is common for people in individualistic cultures to talk about saving face. In sociological terms, face refers to a public self-image. In collectivistic societies, there is an emphasis on protecting the face of others, a concept that is less emphasized in individualistic cultures.

Persuasion Different cultures use different methods for persuading people to un- dertake certain activities or to comply with specific requests.

Expression of Emotion Different cultures express emotions differently and use the display of emotions to further the cultural values.

Information Seeking In all cultures, people attempt to gather information that will clarify situations and reduce anxiety. Members of individualistic and collectivistic cultures go about this task differently. Interestingly, research in- dicates that in America, European Americans tend to self-disclose more than African Americans do. When close friendships are formed, the opposite is true.

Information Seeking Information Seeking

• Try to get to know the person, such as characteristics, beliefs, past experi- ences, and attitudes

• Look for personal similarities with members of an out-group

• Tend to self-disclose to strangers

• Try to get to know the person’s group affiliations, age, and status groups

• Look for group similarities with the out-group member

• Tend not to self-disclose to strangers

Conflict Conflict

• Prefer to deal with conflict directly • Not too concerned that all parties save

face • May look for ways to integrate con-

flicting views or compromise • Not as tolerant of free expression of

a variety of emotions • Negative emotions toward others

are expressed privately so as not to reflect badly on the in-group

• Negative reactions to members of the in-group are withheld so as not to disturb the harmony of the group

• Negative reactions to members of the out-group are more often expressed to increase the cohesion of the in-group

• Prefer to deal with conflict indirectly • Concerned that all parties save face • May try to avoid the conflict or give in

to the other

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FIgURE 4.4 (continued)

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Chapter 4 Cultural Competence 109

In close relationships, African Americans will self-disclose more than will European Americans.

Conflict Look at the differences among cultures in dealing with conflict. Research suggests that “Chinese prefer bargaining and mediation more than North Americans, . . . Mexicans tend to avoid or deny that conflict exists, . . .  Canadians pre- fer negotiation, . . . Nigerians prefer threats more than do Canadians” (Gudykunst and Kim, 1997, p. 282). In the United States, people are more likely to deal directly with conflict, looking openly for ways to resolve it. With all of these cultural differ- ences in the preferences for handling conflict, it is important to approach conflict thoughtfully.

Obstacles to Understanding

We use a number of different mental mechanisms that can block clear communica- tion. These mental mechanisms are used primarily to reduce anxiety when we en- counter strangers. Often we are not aware of the extent to which we resort to these mechanisms. They are particularly present when we are engaging in thoughtless com- munication. The following sections discuss some of the obstacles that prevent real understanding.

Stereotypes

Some stereotypes are positive, and some stereotypes are held only loosely. Commu- nication is most likely to be obstructed by rigidly held, negative stereotypes that can lead a person to make inaccurate assumptions and predictions about another person. Sometimes a person fits our stereotype of a particular group, but many other persons in the same group may not fit the stereotype at all. Becoming aware of our assump- tions and questioning them is important.

Ethnocentrism

Ethnocentrism means that we use the standards common in our own culture to judge the behavior and culture of other people. It is important to understand that we are all ethnocentric to some extent. It is common to look at others through the lens of our own culture. The way our culture is arranged seems “normal” or “correct.” Deviations from our culture, therefore, seem abnormal and incorrect. It is not that we consciously decide to employ ethnocentric tactics, but rather we are socialized into viewing the world in a particular way.

The antidote to ethnocentrism is cultural relativism. Using cultural relativism, we try to understand the meaning of others’ behavior and communication within the context of their culture, not our own. When we use ethnocentrism to judge people

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110 Section 2 Useful Clarifications and attitudes

from other cultures, we create barriers and distance. When we use cultural relativism to understand others, we diminish barriers and distance.

Prejudice

Gudykunst and Kim (1997) define prejudice as “judgment based on previous deci- sions and experiences” (p. 124). People hold prejudices against whole groups of peo- ple and against individual members of those groups when they are encountered.

Prejudice involves an attitude that generally stems from a negative stereotype. If you think all the people in a particular group are pushy and devious, you will prob- ably decide that you do not like those people. Not liking those people is a prejudiced attitude that is based on the stereotype you hold in your head about members of that group. This easily leads to discrimination, in which you take pains to avoid being around these people whom you do not like. You might deny a member of this group a job for which the person is qualified or deny a family of this group housing in your neighborhood.

Conflict

When we are already suspicious or uncomfortable with a group of people, misunder- standings can turn into hostility and conflict very easily, particularly since we are likely to attribute the negative behavior of strangers to their personal characteristics, while attributing the negative behavior of in-group members to the situation. All the mental mechanisms described previously serve to make other groups seem less worthy of being understood and enhance the possibility that conflict will occur with individual members of a particular out-group.

Be aware of two points. First, misunderstandings may stem from mental mecha- nisms that are inaccurate or have obstructed real understanding on everyone’s part. Second, once a conflict has occurred, the approach to resolution may be quite differ- ent from one culture to another.

Changing Attitudes

It appears from recent research that we can change our attitudes toward strangers or members of out-groups through a number of opportunities to interact with them positively. Stephan (1985) talks about ways to increase understanding and to create more favorable relationships among groups. For instance, an emphasis on coopera- tion, rather than on competition, is helpful. It is useful if those coming together have about the same status within their own groups and have some similarities in common with each other. Supporting the individuality of each member helps smooth things out. Voluntary contact and contact that is focused on substantive issues as opposed to superficial issues are more useful. Everyone involved should work toward a positive outcome.

The goal of intergroup cooperation and contact is to learn to see members of other groups as individuals rather than as representatives of our own biases and stereotypes. Gudykunst and Kim (1997) address this in their dichotomy between

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Chapter 4 Cultural Competence 111

uncertainty-oriented people and certainty-oriented individuals. They write about an uncertainty orientation:

Uncertainty oriented people integrate new and old ideas and change their belief system accordingly. They evaluate new ideas and thought on their own merit and do not necessarily compare them with others. Uncertainty oriented people want to understand themselves and their environment. (p. 185)

A certainty orientation is quite the opposite. The authors write:

Certainty oriented people, in contrast, like to hold on to traditional beliefs and have a tendency to reject ideas that are different. Certainty oriented people maintain a sense of self by not examining themselves or their behavior. (p. 185)

When we are communicating thoughtfully, we can make a conscious choice to acquire more of an uncertainty orientation toward new situations and strangers. By remaining open, we can learn more.

We need to go one step further, however, by offering confirmation to others with whom we communicate. When you are working with people who are strangers to you, confirm for those people that they are valuable to you as individuals, that their experi- ences and concerns are important, and that you are willing to become involved in help- ing them to resolve their problems. When we deny that another person’s concerns and experiences are valid and therefore imply that they are insignificant, we demean that person as an individual, and the opportunity for meaningful resolution and rapport is lost.

Competence

Workers who are adaptable to situations and flexible in choosing how to respond to situations do better in cross-cultural communication. These workers are intuitive and sensitive to what others might mean or need and are open to considering the inter- action from a number of different points of view. Figure 4.5 highlights some of the points to remember about individualists and collectivists that might make this pro- cess easier.

Competence in cross-cultural interactions depends very much on the individ- ual worker’s commitment to give high-quality service to every person who comes for assistance. As you begin to practice, you will encounter more people from specific minority groups or cultural groups with which you are unfamiliar. Ethically, you are responsible for developing an understanding of their cultures or subcultures, at least along the various dimensions outlined here.

Until such study has been completed, it is important to consciously and thought- fully monitor your interactions with strangers. Make certain that you hear the sig- nificance of their concerns and experiences, that you respond in a way that lets them know that they have been heard, and that you provide a respectful environment where problems can be resolved.

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112 Section 2 Useful Clarifications and attitudes

Summary

We know that it is not possible to know the particulars of every culture and respond appropriately to individuals from these cultures. While it is your ethical obligation to know more about the culture of people you see regularly in the course of your work, you will encounter people from different cultures from time to time whose culture you know nothing about.

To avoid problems, it is helpful to know whether a person comes from an indi- vidualistic culture or from a collectivistic culture. Once this is established, you are able to respond in keeping with the characteristics of those cultures. In addition, it is always a good idea to check your understanding when conversing with a person from another culture. What seems reasonable to you from the perspective of your own cul- ture may not be reasonable at all to someone from another culture.

Students do better working among many cultures if they keep an open mind and are willing to discard stereotypes and listen for new information. This chapter is

Individualist Characteristics

• There is a degree of emotional attachment from their in-groups. • Behavior cannot be accurately predicted based on group membership. • Out-groups are not seen as extremely different from in-groups. • Equal relationships where status is equal are preferred. • People take pride in their own accomplishments. • Arguments that emphasize harmony and cooperation are not very persuasive. • Saying negative things about others is more likely. • It is easier to separate criticism from the person being criticized. • Long-term relationships happen less often. • Relationships that contain more rewards than costs are more likely to be maintained. • Initial friendliness is not considered a sign of an intimate relationship. • Respect based on age, position, or sex is generally not as likely.

Collectivist Characteristics

• Emphasis is on group membership. • Group membership can be used to predict the collectivists’ behavior. • When group membership changes, the collectivist behavior changes. • Unique relationships, where one has more status than another, are comfortable. • Competition is seen as threatening. • Harmony and cooperation are emphasized. • Keeping a positive public self-image (face) is a concern, and individualists can help

them to maintain that. • Criticism and the person being criticized are not seen as separate; thus, avoiding open

confrontation is best. • Deliberately cultivated long-term relationships work better. • More formal initial interactions are preferred. • Forced self-disclosure will cause a negative response. • Respect for age and position is important.

FIgURE 4.5 points to remember in cross-cultural interactions

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Chapter 4 Cultural Competence 113

designed to give you a starting point for interactions with people from other cultures, but the hope is that you will learn more about other people and their values and norms as you take the opportunity to interact with people from cultures other than your own.

Exercises

These exercises can also be filled out online at CengageBrain.com.

Exercises I: Testing Your Cultural Competence

Instructions: Look at the culture of each client described in the following sce- narios, and decide what might be the underlying issue. What are you thinking about the client as you read each description? What are your first ideas about what con- stitutes the client’s problem? Do you have a problem personally with the behavior of the client, and if so, in what way? The following brief explanations about cul- tural behaviors may help you answer the questions when you read the scenarios that follow:

• In many Asian cultures, members do not talk about family problems, feeling that these are private. They may also pretend that no problems exist.

• In most Asian cultures, crossing the legs and pointing the toe at another person is considered extremely rude. Because members of Asian cultures like to maintain harmony, they would not be likely to tell you directly that they were offended. In addition, in most Asian cultures, waving at another person or indicating that a person should join you by calling the person over with your hand or a finger is also considered extremely rude.

• Asians are not likely to make changes in the family or to engage in discussions about the family unless the male head of the household is present or is consulted. Furthermore, they are likely to tell you things are all right in order to maintain harmony. Things may not be all right. They may also tell you that you were help- ful to them because they assume that is what you want to hear, not because it is true. Telling you what they believe you want to hear will maintain harmony.

• In most Asian cultures, group needs and considerations are more important than individual needs and considerations.

• In most Hispanic families, the man makes the major decisions and expects to be consulted about anything affecting the family. He would not be likely to take his wife’s ideas or concerns into consideration. She would be expected to defer to the husband.

• Many Hispanic families allow mental health problems to persist for a very long time rather than admit that there is a psychiatric problem.

• In Hispanic culture, it is often believed that depression is due to a lack of reli- gious faith.

• In Hispanic culture, mental health problems are often attributed to sin.

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114 Section 2 Useful Clarifications and attitudes

1. A man from Vietnam is in your office because his 11-year-old daughter has been having trouble in school. The school suggested the daughter be tested by your agency. You are doing the intake, but only the father has come into the office. He is very reluctant to tell you any specifics, but talks instead in extreme generali- ties. What might be the reason for his reluctance to talk to you in detail about his daughter’s problems?

2. A Japanese family in the emergency room is seeing you because of a serious ac- cident in which their teenage son was severely injured. During the course of the conversation, you cross your legs so as to be more comfortable. The family con- tinues to talk to you in a polite but superficial manner, and gradually each mem- ber drifts away—to get a soda, to use the restroom, and so on. They are obviously resistant to sitting down with you again.

3. A Chinese woman is hospitalized for a serious infection, and her doctors think she seems depressed over possible home problems. You talk to her, and she ap- pears to reassure you that everything at home is fine. When you come in the next time, she wants you to talk to her husband instead. He, too, is reassuring and pleasant. Later you ask the woman if your talking to her before was helpful, and she smiles and tells you it was. You are not sure.

4. You work in the school counseling office, and you have been asked to help a gifted young Vietnamese student fill out applications to several prestigious col- leges. She is in line for a number of scholarships. She works on the applications, but with obvious reluctance, and indicates she cannot consider going away to school until the family has decided what she will do.

5. After the birth of her fourth child, a Puerto Rican woman is referred for depres- sion by her family doctor. At the intake interview, her husband comes and an- swers all questions. He indicates that he will decide what she needs and what is to be done. The wife says very little and speaks only when she appears to feel her husband wants her to do so.

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Chapter 4 Cultural Competence 115

6. A Mexican American family brings an elderly aunt to the emergency room. The older woman is severely depressed and emaciated. She also appears to be nearly catatonic. She is admitted immediately to the hospital on an emergency com- mitment. You learn that this woman has been in severe depression for years and wonder why the family waited until things became so serious. Later, when you talk to the aunt, she is somewhat improved. She indicates that her pastor visited her and told her that her depression is due to her lack of religious faith. She tells you she agrees with this assessment. She tells you she believes that if her faith was stronger and she was less sinful, she would not feel like this.

7. A young Hispanic woman is admitted to the hospital, and the doctor believes she is showing obvious signs of schizophrenia. She is hallucinating and has not been eating. Her family tells you this problem is the direct result of her sinful behavior. According to them, she is too friendly with the boys in her class. The students often call each other to compare homework, and sometimes a group of boys and girls will go to a party or several boys and girls will walk home from school together. The family has tried to get her to cut off these friendships and to stay home and help her mother more. Because she did not listen, she is being punished.

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Chapter 5 Attitudes and Boundaries 117

Attitudes and Boundaries

Introduction

The way we see other people and the way we relate to them as a result will affect how things turn out in a relationship. The boundaries we erect and the boundaries we fail to observe can similarly have an effect on outcomes. In this chapter, we look at attitudes that facilitate relationships and boundaries that are useful and we consider those atti- tudes and boundaries that are adverse. The purpose is to give you an opportunity to increase your awareness of attitudes and boundaries and to become more observant of your own ways of viewing other people, particularly other people you intend to help.

Understanding Attitudes

Attitudes are extremely important. The feelings you have about other people are bound to be communicated to those people one way or another. If your attitudes are positive and supportive, you will be more likely to establish rapport. If you feel supe- rior or disdainful, no matter how well you try to hide those feelings, they will eventu- ally be communicated to your client, and you will lose a working relationship.

Good human service workers have learned about themselves—their fears, sensi- tivities, and errors in judgment. In facing those things about themselves, these workers have come to understand themselves in a way that enables them to feel understanding and warmth toward themselves and toward others. If you are able to forgive yourself for the mistakes you make and the struggles you have had and see them as an important part of growing, you will recognize that you are basically all right. It is then much easier for you to understand others who are making mistakes and who are struggling with issues and problems. You know that the problems you have faced have provided valu- able lessons. These personal struggles have helped you to grow into a more sensitive and insightful person. Problems and unfortunate decisions happen to everyone. With

C h A p t e r 5

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118 Section 2 Useful Clarifications and Attitudes

this personal understanding, you will be more inclined to see others’ personal struggles as productive of growth, and not necessarily as a reflection of personal inadequacy.

Begin, therefore, with yourself. Be tolerant of your mistakes. Look at yourself objectively. Forgive yourself for errors in judgment, particularly errors that have taught you important lessons or helped you to grow. Recognize that part of being human is to struggle with issues and transitional problems, and that through this process we are often strengthened and given new insight.

Basic Helping Attitudes

You need to bring three basic helping attitudes to your work: warmth, genuineness, and empathy. Studies show that even in the absence of much formal training, work- ers who genuinely care for their clients and are committed to them will be able to help their clients make important changes and move toward better circumstances and increased emotional health.

Warmth

A worker needs to be friendly, nonjudgmental, and receptive. These three attitudes create a warm atmosphere, one that serves to put the client at ease.

In your presence, clients feel valued by you as a person. You communicate a belief to them that they are worthy of being understood. You do this through your actions, body language, and the way you listen to each person. In addition, you refrain from judging what clients say and the actions that they take.

For instance, a warm person would smile at a new client, offer the person a chair and would show genuine interest in why the person came in today. Your capacity to smile at another warms a room and eases tension immeasurably. The atmosphere is cold when there is no smile or the offer of a chair and the worker begins mechanically with a series of questions found on a form.

In addition, you show clearly that you are receptive to what people have to say. You listen to what they tell you they have done and felt, what brought them to seek your assistance in the first place. When you say, “Tell me more about that,” you are inviting the person to open up and talk safely with you. Lacking warmth, a worker might be inclined to judge what the client has said: “It sounds like your decision wasn’t a good one.” Such a response immediately puts the other person at a distance.

Part of being warm is establishing that the client has something to offer in the relationship as well. You come across as respecting your clients’ right to make their own decisions. You may facilitate better decisions than the ones they might have made alone, but ultimately the decisions about their lives are their own, and you will respect that. Sometimes we are painfully aware that a decision is not the right one for the person to pursue. Later in this book, we discuss how you can give clients some of your thoughts in ways that people can hear and use your ideas more easily. Neverthe- less, people may choose to ignore you and make their own decisions, and you will respect that and support the person if need be through the consequences. We have all

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Chapter 5 Attitudes and Boundaries 119

made unfortunate decisions and concluded, as part of our growing process, that they were not very useful.

Some people think being a warm person means that they must stand by pas- sively, never confronting or giving the person another way of looking at things. Warmth means you are able to facilitate change with your support, and change is often painful. As you learn the skills in this course, you will pick up methods to use that help people see things from more than one perspective, to change their direction and possibly see characteristics about themselves that are difficult to face. Warmth is what makes it safe to do that in your presence.

Genuineness

You have heard the expression “be yourself” many times. This is a must for those who help others. Nobody relates well to a phony. People sense when you are not being authentic.

Perhaps you use slang that sounds forced, phrases you do not usually use. Maybe you are using them now to make clients think you are familiar with their lifestyle or culture. Maybe you put on a phony dialect or use profanity to seem more down to earth. You might pretend to be a physician, wearing a white coat and allowing your clients to call you “doctor.” A client calls you “doctor,” and you do not correct the impression. You might pretend to have degrees you do not have. You could use big words you know the client does not understand. None of this is authentic. You will be seen as a person who is pretentious or rather foolish at best, and untrustworthy at worst.

Tom found himself in a hospital setting as a case manager working among doc- tors and therapists, all of whom wore white coats. Tom began to wear a white coat as well and allowed the patients on the psychiatric inpatient unit to call him Dr. Rolland. In doing so, he styled himself as superior to the patients using words they could not understand and giving advice rather than listening. Tom was a likeable person and could have been a real asset to the treatment team. Under these circumstances how- ever, he was avoided by staff who were resentful of his pompous demeanor. Patients too seemed uncertain about what he meant when he spoke so his work with them was not particularly beneficial to them.

Be open and truthful. Strive to be yourself, to present your authentic self to the other person. If you do not know something, say so. If you lost a client’s forms, tell the person that and apologize. If someone asks about your credentials, matter-of-factly tell the person what they are.

Empathy

Empathy in its most basic form means being able to put yourself in the other person’s shoes, but clearly empathy is much more that this. For example, Susan Gair (2012, p. 134) writes that empathy is a “quest . . . to be able to hear, feel, understand and value the stories of others and to convey that felt empathy and understanding back to the client . . . .” It is, according to Gair, “feeling with the client rather than for the client (sympathy)” (p. 135). Other researchers describe empathy in much the same way.

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120 Section 2 Useful Clarifications and Attitudes

Empathy, therefore, is not sympathy. It does not mean that you are so sad for people that you take their situations home and fret about them when you are away from work. It does not mean that you feel sorry for people and communicate the belief that they are poor souls or that their situations are without hope. Sympathy is what we often have for our friends and relations. Empathy involves assessing where the client is at any given moment and being able to express that and support it. Sympathy is the common feeling we have for others in pain. Empathy is a basic clinical strategy for supporting people through difficult times.

Elliot et al. (2011, p. 44) writing in the journal Psychotherapist, describes empathy as “an active on-going effort to stay attuned on a moment-to-moment basis with the client’s communications and unfolding experience.” They go on to write that empa- thy means that the “primary task is to understand experiences rather than words” (p. 47). Other writers refer to empathy as “engagement” with the client on the part of the worker. Still others talk about “making a connection.” Some writers suggest that empathy comes from our common humanity with others and it is this common humanity and our personal awareness of that which allows us to practice empathy.

In summary, empathy involves much more than listening to what another has said and understanding the spoken words. Instead, empathy is the capacity to feel what the client feels and to grasp the significance and impact the client is experienc- ing. To do this well, you need to be able to comprehend the other person’s point of view and see clearly what that person’s needs and feelings are. In human services, we often say that we are able to listen with the third ear. We hear more than what the client is telling us. We hear the underlying emotions, desires, and worries. We see the body language and tune into the tone of voice. With practice we become proficient at this, and we develop a special sensitivity. As Elliot et al. (2011, p. 48) point out, empa- thy means attending “to what is not said, or what is at the periphery of awareness as well as that which is said.”

What do you do with your empathic understanding of the client’s experience? The next part of empathy is being able to accurately communicate to the person an understanding of their emotions and experience. If you can put into words the feel- ing the person is experiencing, you are practicing empathy, but it is much more than words. For example, Lila was talking to her new case manager about the loss of her mother. Lila, the only child of a single mother, was 15 years old and home alone the night her mother died in the final stages of leukemia. Visiting nurses and hospice had all been in the home earlier and hospice came again when Lila called them. However, at the moment her mother died, Lila was alone with her and feeling loss and helpless- ness as her mother slipped away from her.

Her case manager listened intently. She leaned forward toward Lila, her facial expression registering real concern for this young girl. Her words were, “Lila, that must have been so hard for you” and Lila felt heard and understood. She nodded and began to cry. “That must have been so hard for you” can be said in many different ways but said empathically it is heartfelt and accompanied by body language and tone of voice that say clearly that this case manager understood the pain Lila felt that evening.

Further along in this textbook you will learn the skills to respond to people who tell you their problems and worries, but mere words, while they can convey

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Chapter 5 Attitudes and Boundaries 121

understanding, are not enough for the empathic listener. Empathy is expressed with more than words. Body language, tone of voice, and an underlying sense of the pain or the desperation or the sadness of the other person are all part of empathy. Elliot et al. (2011, p. 44) write that empathy is, “an active, ongoing effort to stay attuned on a moment-to-moment basis with the client’s communication and unfolding experi- ence.” And they talk about empathy being “grounded in authentic caring” (p. 48). In her study of the effects of empathy, Warmington (2011, p. 16) writes, “the display of emotions such as kindness or compassion revealed in tone of voice or facial expres- sion is likely to form a stronger bond than the recitation of lines learnt in communica- tions classes alone.”

Empathy and Safety

Most of the research into the effectiveness of empathic listening shows that empa- thy creates a safe space in which the client can express genuine emotions and tacitly gives permission for them to do so. When one is understood, he feels safe enough to explore his problems and issues (Elliot et al., 2011). Empathic engagement with the client creates the space and the permission to fully explore and discuss the issues with which the person is grappling. “(A) sustained effort to understand the kinds of experiences the client has had, both historically and presently” (p. 44).

Empathy and Compassion

Many writers studying this topic link empathy to compassion. When we are empathi- cally engaged with another person who is distressed, we come to feel compassion for that person and a desire to help in some way to alleviate their suffering. Gair (2012) notes that several researchers have “concluded that people feel empathy and want to help” (p. 135). Warmington (2011) talks about a “desire to act to alleviate (the other’s) suffering” (p. 16) and she goes on to say that compassion comes about naturally when we are empathically engaged with the other person. She writes, “(C)ompassion could be said to be complementary and intimately related with empathy” (p. 16). In other words, when we truly see things the way our client sees things, understand her point of view, feel her emotions, a desire to help that person naturally follows.

Empathy and Boundaries

Carl Rogers (1980) wrote at length about empathy. Here are some of the definitions he used to help us understand what empathy is:

• “(Empathy is) the therapist’s sensitive ability to understand the client’s thoughts, feelings, and struggles from the client’s point of view” (p. 85).

• “It means entering the private perceptual world of the other (and) being sensi- tive, moment to moment to the changing felt meanings that flow in this other person” (p. 142).

• Empathy is “an active on-going effort to stay attuned on a moment-to-moment basis with the client’s communications and unfolding experience” (p. 142).

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122 Section 2 Useful Clarifications and Attitudes

Nevertheless, Rogers raised the concern that given this degree of engagement with another person, workers could lose the boundary between themselves and the client. He talks about not losing the “as if” quality of the relationship. In other words, the case manager is fully attuned to the feelings and perspective of the other person “as if” these were his own. However, he does not make them his own.

Numerous writers echo this concern writing that good empathic listeners, such as case managers, could lose themselves in the other’s problems. This can happen when a case manager identifies too closely with the client. Perhaps the case manager is overcome by the client’s feelings of helplessness and therefore cannot construct a solution with the client. Maybe the client’s issues and pain are too close to feelings the case manager has had and therefore the case manager cannot separate her own problems and feelings from those of the client (Warmington, 2011).

The answer to this appears to lie in knowing our boundaries. Gerdes and Segal (2011) tell us that, “true empathy cannot exist without a strong sense of self as separate from the other” (p. 145). They go on to write, “Self awareness allows us to disentangle our own feelings from the feelings of others . . . ” (p. 145). The concern is that the feel- ings of the client can become the feelings of the worker. Gerdes and Segal (2011) point this out. “Without perceptual boundaries (case managers) risk experiencing a client’s feelings of anger, depression, anxiety, or joy as their own feelings” (p. 145).

When we do not have a strong sense of self, we may experience the emotions and issues of the other as if they were our own and we might begin to project our ideas, our motivations and prejudices onto the other person as if these belong to him (Gerdes and Segal, 2011).

In summary, to practice empathy well, you communicate in a way the other person can understand and accept, not in a way that is threatening or judgmental. You com- municate tentatively, aware that you might be wrong or a bit off the mark. You readily accept correction by the client. Empathy is expressed “in the context of positive regard and genuineness . . . . (G)rounded in authentic caring” (Elliot et al., 2011, p. 148).

On Being Judgmental

Harriet blamed the mother of a child she was seeing for the child’s problems. Lily, aged 8, had pica, a condition in which the person eats substances that have no nutritional value, substances that are not food such as dirt, paint, or paper. Harriet was cool and dismissive of the mother when the parent attempted to explain that she felt something physically was wrong with Lily. What Harriet saw was a parent who lived in poverty, who could not possibly, therefore, know what was going on with her child. Harriet thought of the mother as an inadequate parent based on her poverty and lack of schooling. It wasn’t until a psychological evaluation recommended that Lily be tested for anemia or other medical causes for Lily’s behavior that Harriet was willing to consider a medical basis for the problem. Based on the psychologist’s recommendation and not on the mother’s concerns, Harriet set up a medical evaluation for Lily. It turned out later that Lily was extremely anemic and medical interventions were successful in stopping the behavior.

There are human service workers who sit in judgment of clients, applying their own standards to people who are less educated, poorer, or sick. There are clients

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Chapter 5 Attitudes and Boundaries 123

who have been through trauma, or who simply don’t know about alternative ways to approach their lives. There are people who say they are in human services to be help- ful, but who are actually wary and distrustful of their clients. This is an attitude that has no place in the helping relationship.

For example, Rose, a new worker, was part of a planning team for a new shelter that was about to open for children who needed a place to stay before foster care could be found. These were children removed from their homes for physical or sexual abuse or extreme neglect. During the planning, it was decided that the children would earn points for good behavior and lose points when they violated policies of the residence. Children with 10 points or more would get special privileges, and those with no points would stay in their rooms temporarily and miss special activities. The director asked the group, “Where shall we start a child when she comes in new? Shall we start her with 10 points or none?” Rose was convinced that each new child should start with zero points and earn them. “How about starting each child with 10 points and letting her work to keep them?” the director suggested.

When the planning group ultimately adopted the director’s suggestion, Rose was upset, thinking that the children would “just come in here and take advantage of us.” She asserted that the children “need to know we mean business right from the begin- ning.” The assumption that the children would automatically misbehave and take advantage of the staff was judgmental—adding that judgment to the problems the children were already experiencing would have been cruel. Rose’s need to curtail and punish before any misbehavior had taken place would have put her negative attitudes into action in a destructive way.

A judgmental worker is one who measures people by rigid or irrelevant stan- dards. Often, these standards have to do with what the worker assumes about certain people or how the worker feels about others. In addition, judgments are often based on ideas about what people should do or how people should act or live and not on the actual context in which the person lives and functions.

Reality Check

Some human service workers say they have gone into this work to help other people, but the minute a client behaves in a difficult manner, they complain that they should not have to deal with this sort of person. Clients who don’t cooperate, who do not show gratitude but are demanding instead, or who are rude throw these workers off balance.

Rita refused to sit down with the mother of a child who was in treatment and work with her on a solution to the child’s behavior problems. Rita complained that the mother was a difficult person to work with. “She’s always complaining about what we’re doing. She thinks she has a better way. I just want to say to her, ‘Look, if your way was so hot, you wouldn’t have the problems you’ve got with Benny.’ All she ever does is make stupid suggestions. I just wasn’t going to get into that with her.”

In human services, we are trained to deal with people who seem dissatisfied and upset. We expect to meet people who do not see things our way, who are chal- lenging, or who question our decisions. Many of the people we work for will have

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124 Section 2 Useful Clarifications and Attitudes

an inaccurate perception of reality or difficulty expressing what concerns them, seem unduly sensitive, or be confused about following a plan. This is largely the reason our clients sought our help in the first place. If we only want to work with people whom we like and who agree with us, people who give us no trouble, we will be barely effec- tive and more likely harmful. Just because people do not behave exactly the way we would like is not an excuse to provide poor service.

Rita and others like her have the false impression that clients should be grateful and cooperate with suggestions. For workers like Rita, the reasons for rude behavior or a lack of cooperation are reasons to deny good service and complain about feeling unappreciated. Their attitude is not realistic for human services work.

How Clients Are Discouraged

There are many ways to discourage another person. You could set up a competition com- paring the client to others or to yourself. You could push, force, or shame the client into moving toward some goal. You could spend an inordinate amount of time focusing on the person’s mistakes or demand that the person do more or try harder. You could insist that clients do things your way, dominate clients by taking over or demanding perfection or unrealistic outcomes, or intimidate the person with threats. You could treat clients like “poor souls”—incompetent, bumbling people who need you to do everything for them.

You could be discouraging with your insensitivity by failing to notice positive changes, ignoring the good things people accomplish, failing to mention the positive changes or your clients’ strengths. You could refrain from ever giving feedback except the most negative type. All of these responses are discouraging and introduce a negative element into what should be a helping relationship. Discouragement is never helpful.

Today, many individuals, some of whom hold degrees in fields unrelated to human services, are being asked to give direct care to people who seem odd and unusual to them. For this reason, the clients may be frightening to these workers. In order to counteract feelings of uncertainty, such a worker may become extremely dominating and coercive. This gives a false sense of control. The domination and need to order clients’ lives in inappropriate ways are discouraging to people who are learning to take charge of their lives and make decisions.

An example of this occurred in a program for individuals recently released from an institution for those with intellectual disabilities. A case manager visited her clients every other day in their apartments, where she offered support to help them remain in the community. She enjoyed working with her clients, and she had received good human service training. When the clients began to make jokes about the pounds they had gained over the years in the institution, she suggested they might want to exercise. Together they decided that walking around the apartment complex might be fun and a good way to meet their neighbors. For weeks, the clients walked almost every day, but at different times of the day and not on days when the weather was too cold or snowy.

Later, the case manager’s supervisor, a person with little human service experi- ence, was upset that the case manager had not “scheduled the exercise.” The supervi- sor felt that the clients should not be allowed to just say they would walk every day

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Chapter 5 Attitudes and Boundaries 125

“because they won’t do it. We need to put that in their daily schedule, let’s see, at 11:00 to 11:30 every morning. That way we can check on them and be sure they are doing it.” The case manager asked, “But what if they skip one day, or feel like going at 3:00 in the afternoon?” The supervisor replied, “My point exactly. This way they have no choice, and they’ll meet their goals. We’ll look good for seeing that the cli- ents’ goals are implemented consistently. Set up a daily schedule for them, and see that exercise goes into it at 11:00.” A person beginning to live a normal life in a com- munity, who has decided to take up an exercise program, and who has demonstrated a commitment to that program, does not need a professional to oversee the timing of it. This is an example of inappropriate control. In this case, the walking program fell apart as clients had other things to do or felt coerced by the program director.

A very grave example of discouragement occurred in a partial hospitalization pro- gram. Kitty, a client in the program, suffered from severe schizophrenia and depres- sion. Often she was immobilized with sieges of despair and delusions, with voices of many others talking to her in what she called a “confused conversation.” Kitty described herself as afraid and appeared to the staff as dependent. The staff surmised that because Kitty had a master’s degree, obtained before her first episode of depres- sion, she was really capable of more independence. They developed a series of goals for her to follow, such as riding the bus, shopping at the mall, and handling arrange- ments for her insurance and transportation. The final step on the list of goals was for Kitty to prepare her tax returns because her degree had been in business.

From the start, Kitty had problems managing the goals. Feeling extremely depressed and occasionally hearing voices, Kitty found it alarming to be on her own in the city. In group sessions, Wayne, the group leader, held her up to ridicule. He encour- aged the other clients to scold Kitty and accused her of refusing to help herself more. Kitty asked to reexamine her list of goals, but this was greeted with a refusal on the part of the staff and further insistence that she “get out there and try harder.” Finally, Kitty decided to withdraw from the program. When she told the staff of her decision, they told her that unless she cooperated with the program set forth for her, she would not be allowed to come to the clinic for her prescriptions. These prescriptions, partially underwritten with public funds, were important in sustaining Kitty’s connection to reality. Kitty finally called a friend of hers, a psychologist who worked in the state men- tal health system. When the behavior of the staff came to light, staff members were reprimanded and Kitty obtained her prescriptions and counseling services elsewhere.

We need to examine what went on in Kitty’s case. First, a client has the right to ask that goals be reexamined. It may indeed be that the goals are not truly in line with the capabilities of the client, and setting goals should always be a collaborative effort. Second, a client can always withdraw from service if the client determines the service is no longer useful or, as in Kitty’s case, is actually harmful. The client has a clear right to determine what is good for and helpful to her, and what is not. Finally, the use of medication to coerce the client into doing what the staff has determined she will do is highly unethical.

All these factors combined in Kitty’s case to create a discouraging atmosphere. On top of that was the denigration by the staff, particularly Wayne, who pointed out Kitty’s deficiencies and ascribed manipulative motives to her failures without ever really working with her to plan goals at which she could succeed. It would have been

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126 Section 2 Useful Clarifications and Attitudes

hard for a person like Kitty to attempt any goals in such a negative situation. Kitty was deeply discouraged by the actions of the program and made no progress there.

Another example of discouragement happened in a transitional living arrange- ment for the mentally ill. This transitional living situation was one of many living arrangements with varying degrees of independence that helped clients move from hospitalization to independent living. Mario, who had persistent schizophrenia, had been placed in the last step toward independence, a small house with four other cli- ents. At the time, Mario was on new medication, begun while he was in the hospital, which increased his ability to function considerably. While in the program, he adjusted well to the medication, obtained a job, and began to look for a new apartment.

This was all part of the plan. Finding a new apartment was difficult, however; while extremely ill many years before, he had presented problems for one landlord after another. Now, in spite of the obvious improvement, Mario had a reputation for being a problem when he became ill, and no one was willing to risk his becoming a tenant. In the meantime, Mario collected furniture for a new apartment and contin- ued to look at ads in the paper. Staff in the program assisted.

The time for Mario to remain in transitional housing expired. At that point, the case manager called the assistant director of the agency. The case manager was bel- ligerent. He said the client was obviously “high functioning” and was therefore “stall- ing” in finding a place and moving on. He stated he knew nothing about the client’s past history with landlords and was not interested. He reminded the program director that case management was responsible for the bills for the transitional housing, and they were going to stop paying for this service for this “manipulative” client.

“He obviously has no intention of moving and thinks we’re all too dumb to see it,” the case manager claimed. “Let him know he has 7 days to be out.” Without ask- ing for a meeting, without sitting down with Mario or with the staff in the program, without looking at what might be going on and how the agencies could work together to facilitate a positive transfer to conventional housing, the assistant agency director wrote a peremptory and hostile eviction letter, making it clear that Mario had 7 days to find housing or he would be “evicted,” and stating that Mario’s case manager sup- ported this decision and thus Mario should make no appeal to his case manager for help. Coming home from work, Mario found the letter on his pillow and immediately deteriorated. Staff at his transitional living program had not been informed of the let- ter and discovered the client in a frenzy in his room, throwing things into garbage bags and crying. Sometime later he left the house.

When he did not return that evening, the staff became alarmed. They found and read the letter left in his room, but were unsure what to do. They notified the evening supervisor of another of the agency’s programs, and together they were able to track Mario down in another state where he had gone to be with his sister. Much later, case managers and others began to put notes in the record that indicated work had been done to find housing with this client. The notes were made to appear as if they had been written long before he left the program and that the case manager had actively tried to assist Mario. The notes were back-dated, a highly unethical practice. These notes contained indications that the client had been uncooperative during this time, something the transitional housing staff firmly denied.

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Chapter 5 Attitudes and Boundaries 127

In time, the staff in transitional housing was able to let the executive director of the agency know of the true nature of the incident. The executive director had been told this was a smooth leave-taking by the client. Reprimands followed, but these in no way made up for the damage done to the client’s sense of self-esteem and confidence or the ground lost in this client’s move toward independence. Mario was discouraged in the sense that the circumstances related to the eviction caused him to lose ground and confidence in himself. What had been gained had been lost.

A Further Understanding of Boundaries

There is always a danger that we will see ourselves in the clients we serve. Many of us will work in agencies that serve people who have been through something we went through ourselves. We may meet a person whose situation is different but that person reminds us in some way of ourselves. Perhaps the person is our age or has the same interests we do. When clients remind you of yourself and you are unable to separate your circumstances from theirs, you will become an obstacle to the person you are supposed to be helping. Sometimes we have not entirely resolved the issues in our own life. We may seek employment in an agency that deals with similar problems just to continue to heal. This is not useful. It means that the clients will be treated in the light of your own issues rather than with a completely objective focus on their own personal issues.

Sometimes to protect ourselves, to feel superior, to exercise power we erect unnecessary boundaries that are really barriers to good service. As the case manager, you are the person responsible for maintaining useful boundaries and refusing to erect those that are not helpful.

Seeing Yourself and the Client as Completely Separate Individuals

The Client Reminds You of You

A young woman volunteer who was in training to answer the hotline at a rape crisis center had been raped some years before. It was still an overwhelming event to her, the defining event in her life. She was not ready to begin to work with others who had been raped while her own emotions were so raw and intense. During the training, she would fret and stew over the information being given. She would constantly remind the trainer that this would not have worked for her in her situation because she was too upset or too badly injured. She pointed out her own circumstances and told the trainer to focus more on situations similar to hers. She gave details of her rape at every opportunity. She used her own situation to illustrate the trainer’s points.

It was apparent that she was not ready to serve as a volunteer who would have direct contact with the clients. Why? She had not yet recovered from the trauma of her own rape, and it seemed likely that she would impose the circumstances and emotions of her own rape onto those of the caller. In that case, the caller’s real problems might get lost as the worker went off on her own concerns and feelings. She was asked to take

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128 Section 2 Useful Clarifications and Attitudes

other work in the agency, and ultimately she left because she never was able to separate her rape from those of the clients the agency served. Her rape and trauma were the same as all other rapes and traumas and she could not distinguish the difference among them.

Sometimes the client is trying to do something we accomplished ourselves long ago. The client reminds us of a time when we were vulnerable and uncertain. For example, in a welfare agency, a young woman, recently off welfare and now working as an income maintenance clerk, was helping a welfare client make plans to get off welfare. The worker was somewhat irritated by the client’s concerns about day care and transportation. “Look,” she finally blurted out, “If I can work every day, you cer- tainly can!” Here the worker was viewing her client’s life through her own life and circumstances, blurring the boundaries between them.

In another situation, the similarities were too much for Yolanda, a human service worker, to tolerate. She went to great lengths to find differences between herself and the client. Working at a program for individuals recovering from alcohol abuse, she had trouble understanding how one of the clients could have “gotten into a mess like this.” The client had regressed over the weekend and was drinking again. She came in seeking Yolanda’s help, but Yolanda had been through recovery and this woman’s “slip” reminded her of the hard fight she had made to stay sober and clean. What made it harder for Yolanda was that this woman was Yolanda’s age, had two children the same ages as Yolanda’s children, and lived two blocks from Yolanda. Instead of listening to where the client was at the moment, Yolanda became angry, asserting how hard she had fought to get where she was and telling this person to do the same. This woman’s relapse threatened Yolanda’s view of her own success. It became important, therefore, to demand that the client straighten up and never, ever think of doing this again. Her anger and refusal to start where the client was at the moment alienated the person. In subsequent meetings, Yolanda pestered the woman to tell whether she had relapsed since her last visit, and she admonished the woman frequently about her “tendency to drink.” Gradually the client drifted out of the program.

When the client reminds us of ourselves, we may push people to do things that we did to successfully resolve our own similar problem or push the client to take a particular course of action. Our life and circumstances are superimposed on the cli- ent’s life and circumstances, blurring the distinctions between the two.

The Client Reflects on You

There are other reasons that a human service worker might not separate from the cli- ent. As a case manager, you might become extremely involved in clients’ problems and solutions because it makes you feel more important or competent if the clients solve their problems successfully. It may impress others if all your clients do well, and so you may cross the boundary and force people to use your solutions. Sometimes, in spite of what we know about how good it is for individuals to learn from their errors and struggles, and in spite of our belief that people are responsible for their own lives, we also mistakenly believe that all our clients must be happy and successful if we are to look good. Again, we are focusing inappropriately on ourselves, and not on the clients’ needs. Pushing people so that we ourselves look competent is unprofessional.

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Chapter 5 Attitudes and Boundaries 129

Erecting Detrimental Boundaries

False Attributions

Some boundaries are artificial and inappropriate. There is a very human tendency to make these two extremely unfortunate assumptions about people:

1. People who look like me will think and act like me. 2. People who do not look like me are not like me at all, but very different.

Neither of these assumptions is necessarily true. A person who comes from your race or culture may not share your values or circumstances. We need to watch for signs that these assumptions are not creeping into our thinking because these ideas erect negative boundaries that can make you ineffective.

Be very careful what you assume to be true of another person. A person may be of another race or culture and yet share many of your values and circumstances. A person who looks like you may be quite different in tastes, opinions, and way of life. If you assume a person of another race or religion has certain stereotypical characteris- tics, you will be dealing with a stereotype, and not with a real person.

When you view people in light of these assumptions, you no longer see indi- vidual differences. All Catholics, African Americans, Jews, Quakers, and Indians are not alike. If you view people based on your stereotypes of the groups from which they come, you will fail to discern individual differences. Failure to perceive individual dif- ferences is a failure to accurately perceive reality. Aside from this being a fundamental characteristic of mental illness, it is impossible to give excellent service to a person you see only as a stereotype.

False Power

Another unsuitable boundary that acts as a barrier or more like a barricade is our own need to display authority, competence, and power. In this way we may intimidate our clients and threaten them as Wayne did to Kitty. We may stop collaborating and give orders instead, as Tom did on the psychiatric inpatient unit. This way of working with people may make us feel important and all-knowing, but it will not help the client.

Transference and Countertransference

Transference

Sometimes, when working with other people, you will find that you remind one of your clients of someone in their past. Sometimes clients are only dimly aware of that. They simply know that there is something about you that they really like or really dislike. This is transference, a collection of feelings and attitudes the client holds about you. Positive transference occurs when the client likes you, and negative trans- ference occurs when the client does not. Understanding this is one more reason why it is important that you not take the feelings of clients personally.

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130 Section 2 Useful Clarifications and Attitudes

In addition, clients can start out with positive transference toward you but then find those feelings changing. Perhaps a client hopes to make the relationship with you into a friendship. When you maintain professional boundaries, the client may reverse the positive feelings and the transference may become negative.

As a competent case manager, you will want to accept transference when it exists. It is not a good or a bad thing. It is something that commonly takes place in helping relationships. In other words, practice acceptance rather than becoming threatened and defensive. There will be times when clients’ behaviors seem irrational, hostile, or even overly seductive. Acceptance of such behaviors while maintaining professional bound- aries prevents negative barriers from developing and allows people to continue to feel safe. In that environment, the clients may be able to reevaluate their feelings about you.

It is helpful, when clients respond in unexpected and seemingly somewhat inap- propriate ways to the situation, to use reflective listening. This allows people to know that you are not judging their behavior or attitudes and that you have heard them and want to understand. This, in turn, creates the safe environment you are seeking to maintain.

Sometimes this is how dual romantic relationships get started. The client sees in you a romantic partner based on experiences he had outside the agency. His seduc- tiveness may be just what a particular worker needs at the moment and a romantic relationship begins. For this reason, remind yourself of transference when a client behaves in ways that seem inappropriate to the situation.

Countertransference

In countertransference, the case manager projects onto the client certain emotions and attitudes because the person reminds the case manager of someone from the case manager’s past or because the client’s issues and situation cause the case manager to identify with that person. This can arouse both positive and negative emotional responses from the case manager toward the client. A case manager may give special favors to someone who is reminiscent of an elderly aunt the worker once loved and who is now deceased. On the other hand, the worker may be inappropriately demand- ing when the client reminds him of a younger brother who was always bullying the worker when they were kids.

Acceptance of yourself and your feelings is extremely important here. We will meet people throughout our lives who remind us of other people. When it affects the way we work with our clients, then we need to be very aware of our feelings. Countertransfer- ence feelings are often a good warning signal that we have old issues we need to resolve. It is never acceptable to allow these feelings to interfere with service to your client.

Summary

Many, many good therapeutic approaches have been developed after years of study and trial and error. In addition to all of these, researchers have found that warmth, genuineness, and empathy have a profound effect on clients’ ability to move forward and heal. Many students begin this course of study intending someday to become

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Chapter 5 Attitudes and Boundaries 131

therapists and counselors. Learning how to convey these three essential elements of a therapeutic relationship is where a true therapeutic relationship starts.

Using the ideas in this chapter, you will recognize discouragement and know how to encourage and motivate your clients. Putting aside what you want for your clients and starting where your clients are gives them the footing they need to move to something better. The three basic elements of warmth, genuineness, and empathy form the underlying foundation for everything else you will do with people. Even when you are uncertain about how to proceed, if you are using these elements, your actions will nearly always be viewed by others as supportive.

In addition, it is important, for all the reasons stated in this chapter, to view each client as an individual person and to work very hard to understand what makes this person a unique human being. Through careful listening and observation you come to understand what it is that makes your client a unique person. Professionals work against relying on stereotypes, assumptions about groups of people, and personal feelings about certain problems and their solutions that will color the work they do with others. Take the time to see and hear the characteristics, circumstances, and interests of this person who is trusting you to assist in some way. Focus on what makes your clients separate individuals. Give your service based on what you know about the person as unique.

When workers begin to identify too strongly with their clients, or feel that they must assume some of their clients’ responsibilities, they have blurred the boundary that makes both the worker and the client separate individuals. They cross that boundary in unproductive ways every time they assume that a person will be like them or will react as they would. These workers breach the boundary each time they handle a client’s problem without collaborating with the client, whom they fail to see as distinct.

Exercises

These exercises can also be filled out online at CengageBrain.com.

Exercises I: Demonstrating Warmth, Genuineness, and Empathy

Instructions: There are five grade levels of responses you might give to people who have come to you needing assistance in sorting out their problems and feelings.

Grade A. These responses are the most useful in establishing rapport and encour- aging a continued dialogue:

• Centers on the client entirely • Stays on the topic (responds to the client’s feelings or the content of what the

client has said) • Addresses what is most important at that moment to the client • Is respectful (indicates the client is an equal; indicates the client is a person wor-

thy of being understood) • Invites collaboration • Shows confidence in the client

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132 Section 2 Useful Clarifications and Attitudes

Grade B. These responses are helpful but could be better:

• Is somewhat confident of the client’s abilities • Minimal invitation to collaborate • May briefly stray off the topic • Is just a little superior

Grade C. These responses are usually made by someone who means well, but they are not especially helpful responses:

• Is pleasant, but superior • Overly helpful without collaborating • Introduces new topics that seem to the worker to be more relevant • Misses the feelings • Does not address the content • Confuses the worker’s situation with the client’s situation

Grade D. These responses are not useful in establishing rapport and do not encour- age a further exchange:

• Takes over with solutions • Spends little time listening; is abrupt • Moralizes and preaches • Ignores the client’s assets and strengths • Shows minimal interest • Does not indicate respect for the client

Grade F. These responses are mean-spirited and damage the relationship irreparably:

• Uses denigrating labels and descriptions of the client or the client’s actions • Shows no interest in the client • Denigrates feelings of the client • Denigrates the content of what the client has said • Intimidates, humiliates, or threatens the client (berates and scolds the client) • Leaves the topic for one entirely unrelated

Following are some vignettes that demonstrate the various grade levels of responses. Look at each response, and assign a grade to each one. Next, using the pre- ceding material on grade levels, tell specifically why you think the response should receive the grade you assigned to it.

Vignette 1

A man has come to your agency for help after he lost everything in a fire. The worker asks the man to tell her what happened. He describes the night the fire took place, but as he approaches the actual incident, he finds it more and more difficult to talk.

first worker’s response: “This is really difficult for you. Would you like to wait a minute?”

Grade: Reason:

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Chapter 5 Attitudes and Boundaries 133

second worker’s response: “Now, this is all over, Mr. Brown. It happened days ago. You need to be thinking about moving on and getting on with your life.”

Grade: Reason:

third worker’s response: “This must have been awful for you! Excuse me a minute.” Turn- ing to the secretary in another room, “I heard the phone ring, Sue. Was that the attorney call- ing? Tell him that we need that file before we can do anything for his client.” Turning back to the client, “Now, where were we, Mr. Brown?”

Grade: Reason:

fourth worker’s response: “I’m really wondering if you can handle this! I’m going to call mental health and set up an appointment for you. Why, you’re a wreck!”

Grade: Reason:

fifth worker’s response: “I can see it’s difficult for you to talk about this. I’d like to work with you to see if we can find some ways to help you. I have some thoughts that I think might help, and I’m sure you do too.”

Grade: Reason:

Vignette 2

A young woman enters a shelter after she and her boyfriend, with whom she is living, have had a fight. She has been badly beaten. She seems to want to talk and remains in the office even after the worker has completed the admitting forms. She is rather quiet, however, and does not volunteer much information.

first worker’s response: “Yeah, another case of the violent boyfriend. Here we go again. You’d think you women would stop seeing these guys before it gets to this.”

Grade: Reason:

second worker’s response: “Did he ever beat you before? I was just wondering because I’d think that if I’d been through this before, I would have left before now.”

Grade: Reason:

third worker’s response: “It sounds like you’ve had a rough evening. Do you own your own home? No, I was just wondering if you own your own home. It says here you live in a house, and not an apartment.”

Grade: Reason:

fourth worker’s response: “I was in your shoes once. Believe me, it was a long and difficult battle to get out of that mess. But I did. I just decided that it wasn’t worth living like that— life’s too short, and I got out!”

Grade: Reason:

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134 Section 2 Useful Clarifications and Attitudes

fifth worker’s response: “What you need is a good lawyer. You tell the staff that comes on in the morning that you want to talk to a lawyer. You can’t just sit around and take this stuff!”

Grade: Reason:

Vignette 3

A rape victim sees the volunteer in the emergency room. As the volunteer talks to her, she learns that the victim is afraid to go home. The man who raped her is an acquain- tance in the neighborhood, and she is afraid that now that he knows she called the police, he will come after her.

first volunteer’s response: “It sounds like you could use a place to stay tonight. Would you like me to try to set something up for you?”

Grade: Reason:

second volunteer’s response: “You’re really afraid of this guy! Well, you’re not going home tonight.”

Grade: Reason:

third volunteer’s response: “I can see that you can’t handle this! I’ll make all the arrange- ments. Don’t worry about a thing. I’ll get you a place to stay, and I’ll set you up with an appointment at mental health.”

Grade: Reason:

fourth volunteer’s response: “How would you like to handle this tonight?”

Grade: Reason:

fifth volunteer’s response: “Let’s get off this gruesome topic. I mean, I know it’s important to you right now, but it’ll do you good to talk about something else. Tell me about your job.”

Grade: Reason:

sixth volunteer’s response: “You must be feeling so afraid of him.”

Grade: Reason:

Vignette 4

A young woman comes in because she has been using “crack more than I thought I would.” She describes having trouble staying away from crack as her roommate uses it. Recently her roommate has begun prostituting herself to get the money for drugs and many of this woman’s possessions have disappeared. She says, “I just think I am headed in a bad direction and decided this morning that I need help to get out of this.”

first worker’s response: “Can you tell a little more about what is going on with your roommate?”

Grade: Reason:

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Chapter 5 Attitudes and Boundaries 135

second worker’s response: “How did you get mixed up with this roommate to begin with?”

Grade: Reason:

third worker’s response: “I know this other woman who is in a similar situation and she is having the worst time getting away from her roommate!”

Grade: Reason:

fourth worker’s response: “Okay. So what we are going to do here is get you to sign papers to go into a rehab unit. That will get you out of the house and away from the roommate. Then we are going to get your things out of that house. Do you have a place you can store everything while you are in rehab?”

Grade: Reason:

fifth worker’s response: “You must feel betrayed by her. Talk to me a minute about what you would like to see happen for you right now.”

Grade: Reason:

Vignette 5

A man talks to the intake worker in a case management unit about his recent separa- tion from his wife. He comments that he could have been a better husband, that he was stingy and went for days not speaking to his wife if he was annoyed. He thought he was making her see how he felt about things, but she left him, saying he was “uncommunicative.” He seems depressed and bewildered by his wife’s departure.

first worker’s response: “Sounds to me like you could use some communication workshops.”

Grade: Reason:

second worker’s response: “Did you have to go that long without speaking? I mean, I can’t think of what she could have done that made you that mad?”

Grade: Reason:

third worker’s response: “You really thought you were getting through to her, so it must be hard to see her leave this way.”

Grade: Reason:

fourth worker’s response: “Only a fool would think what you were doing was ‘communica- tion’! Of course she didn’t hear you, fellow!”

Grade: Reason:

fifth worker’s response: “See, I think you should have tried marriage counseling before things got this bad. Not now, after she’s already gone.”

Grade: Reason:

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136 Section 2 Useful Clarifications and Attitudes

sixth worker’s response: “Well, if you had a better understanding of the way women think, you could have avoided this whole thing.”

Grade: Reason:

Exercises II: Recognizing the Difference—Encouragement or Discouragement

Instructions: Following are two vignettes. Decide what you would do or say to en- courage the person, and then decide what you might do or say that would discourage the person. Actually picture yourself as an encouraging person, and then as a discour- aging person. Remember your actions may be as important as your words. Write in your answers to share with the group.

1. A woman, the mother of two children, has been without a home for a number of months. She tells you she really wants a permanent place to stay. You know there are very few places she can go. You also know she has some talents and interests—strengths that might be to her benefit.

You encourage her by:

You discourage her by:

2. A man calls and says he was sexually abused as a child. It has come to haunt him recently, but he is not sure where he should turn for help.

You encourage him by:

You discourage him by:

Exercises III: Blurred Boundaries

Instructions: Following are some situations in which the boundary between the worker and the client has become blurred. Identify what went wrong and what needs to happen to correct the situation. Use the space provided to make notes.

1. Alice is very upset because she gave the client some names of people she thought might be helpful in solving the client’s problem. Today, she met one of those people at the local deli where she eats lunch and learned that the client

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Chapter 5 Attitudes and Boundaries 137

has never been in touch with that person. She has been trying to call the client all afternoon to find out what happened.

2. Bill is feeling very proud of himself. He talked to a man who had very compli- cated problems this afternoon. He put everything down on paper, while the man sat by his desk and drank a soft drink. Then Bill decided on the best way to handle the situation. The man finished his drink, did just what Bill suggested, and reported that everything is fine now.

3. Mary Lou was once in a very abusive relationship. She was able, through much counseling and grit, to become assertive enough in her own behalf to get out of the situation. Today, she is happily married and the mother of two lovely chil- dren. The client she is talking to is in just such an abusive situation and seems hesitant about leaving. Mary Lou wants her to leave and, using examples from her own life, assures the client she is certain the client will have just as happy a life as Mary Lou now has, if she will leave. Mary Lou remembers vividly how she felt when she was in the woman’s shoes and tries to make the woman see how much better she will be if she leaves now.

4. Gloria was raped by her stepbrother when she was 16 and he was 23. It was a very difficult situation; law enforcement officials were called, and eventually the situation broke up her family. She is currently working at a rape crisis center and is talking to a client whose situation reminds her of her own. She says things like: “Oh, telling my teacher wouldn’t have done a thing for me!” or “I was too far gone to be able to handle it the way you did.”

5. Carlos is working with a woman whose father is the president of a large bank in another city. She has become depressed and needs a referral to a therapist and perhaps a psychiatric assessment. Carlos is reluctant to talk to her about needing “psychiatric help” because he assumes this would be offensive to someone as “upper class” as she is. Instead, he suggests she “talk to someone for a little bit.” Later, with the woman’s permission, her father contacts Carlos and asks if there is anything he can do. Carlos is careful not to suggest short-term psychiatric hos- pitalization even though the father is offering to pay “for whatever she needs.” Carlos is sure such a hospitalization would alienate the father.

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138 Section 2 Useful Clarifications and Attitudes

6. Candy is working in a shelter for homeless men. She is new at her job and enjoys what she is doing. The fact that many of the men are in poor physical health and are unwashed is of great concern to her, and she works hard to meet the basic needs of the residents, such as food and clothing and a warm place to sleep. When she is working, she never asks the men to help with chores around the shelter even though that is a condition for their staying there. She thinks of her work as very loving and giving, and she sees the clients as hapless and unedu- cated. Therefore, when Paul comes to her and tells her he graduated from high school and finished a year of college before he got hooked on drugs, she is not certain she believes him. When he asks for help returning to college, she resists giving him information and support for attending the local community college.

7. Marissa is interviewing a woman who has come in for help with her bills and job-readiness training. The woman is the mother of a 2-year-old boy. Marissa is the mother of a 2-year-old boy as well. She considers herself an excellent mother. She prides herself on how she adapts her life around the needs of her child and how his needs come first. She is uncomfortable with the arrangements the woman must make to accommodate her impoverished circumstances, and so Marissa lectures the woman. “Children need stability, not instability and dis- organization. They need to know you are there for them and not have continual disruptions. Does your son even know ahead of time when he will be staying with your mother and when he will be staying with you? You need to put this child first in your planning.” Marissa is surprised when the woman remarks qui- etly that seeking help so that she and her son can eat on a regular basis is putting her child first.

8. Harold is seeing a man who is coming out of rehab after years of drinking. Remembering how hard it had been for him to find a job and a place to live away from his drinking buddies, Harold begins with a lecture on how to find a job and how to stay away from “the guys you used to drink with.” The man looks puzzled and says that he is returning home to his wife and family and his job at a large corporation and came to see Harold for help with services to maintain his sobriety.

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Chapter 6 Clarifying Who Owns the Problem 139

Clarifying Who Owns the Problem

Introduction

Before you ever open your mouth, before you ever say a word to your client, you want to be able to discern accurately who owns the problem. Who owns the problem?

It is the person whose needs are not being met.

It is not the person who is being rude and uncooperative. It is not the person who is ruining a party. It is not the person on our caseload who has begun to drink again. Nor is it the person who is singing off-key and ruining a songfest. It is the person whose needs are not being met. You should know who owns the problem for four very good reasons:

1. You will know who is responsible for solving the problem. If you know who owns the problem, then you know who is ultimately responsible for solving it. If you know who is responsible for finding a solution, you will not assume the entire respon- sibility is yours. In other words, you will not accept responsibility for problems that are not yours. When you take over and try to solve other people’s problems for them, or tell them how they should resolve their problems, you may be seen as meddling in their affairs or being pushy.

2. Meddling is disrespectful. This sort of meddling is disrespectful, even when you in- tend it to be helpful. It says clearly that you have doubts about the client’s abil- ity to figure the problem out and handle it on her own. You indicate that you are not sure other people have the sense and insight to know what is best for them.

3. Boundaries are clarified. Understanding whose problem this is clarifies boundaries. We do not cross boundaries into other people’s affairs if we are clear about what issues and problems belong to them. We help where we can and we let people help themselves where they can, growing and learning as a result.

C h a P t e r 6

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140 Section 2 Useful Clarifications and attitudes

4. The client loses opportunities to grow. Furthermore, when you take over with solu- tions, you interfere with what might be a very meaningful experience for the client. This person may grow from wrestling with this issue. It may be the oppor- tunity needed to gain insight, learn a new skill, or try something that until now has been too frightening. If you attempt to take over with your own solutions and ideas, your client will miss this valuable opportunity. Clients can never say, “I did this myself!” Instead, they will have to say, “My case manager did this for me.”

Just because a person tells you about a problem does not mean you must solve it. Kentaro, working in a sheltered workshop, was learning a new job on the assem-

bly line. He seemed to quickly pick up his responsibilities, but he was having trouble keeping up. Over and over, the worker monitored his progress and gave him tips for improving his speed. The worker stood behind him and grabbed the pieces Kentaro missed. Finally, the worker was called away to the phone. When he came back, he discovered that Kentaro was sitting so that he faced the assembly line from a differ- ent position. Now, with better visibility, the client was catching each piece that came toward him and making the necessary adjustments. The worker later said he felt fool- ish for standing over Kentaro all morning when it turned out the client knew all along how to solve the problem.

Agnes wanted to have a better relationship with her mother. She confided this to her worker one day, and the worker set about helping her solve the problem. While the worker spoke to her about poor communication, mother and daughter relation- ships, and family therapy, Agnes decided to buy a pretty card and send it to her mother. In the card she told her mother how much their relationship meant to her and how much she wanted them to be friends. She enclosed a little lace handkerchief, and sent the package off to her mother. Soon her mother called Agnes, and they began to talk. Agnes, who knew herself and who had lived a good portion of her life with her mother, understood how best to solve her problem. Listening and helping Agnes talk about the relationship with her mother might have been a better course of action for the worker.

Keep people in a position of authority over their lives to the greatest extent pos- sible. Be mindful of the boundaries between you and let people resolve their issues as much as they can on their own. Remind people who have resolved an issue of how much of the resolution was their own doing. Point it out to them. You might say, “Let’s look at all the things you’ve done to make this happen.” Make sure your clients have the opportunity to feel pride in their part in solving the problem. Let people see they can help themselves more (even if it is only a little bit more) the next time, rather than turning to their case manager to solve the problem for them.

Boundaries and Power

Who owns the problem and who should solve this problem is a matter of boundar- ies. People seek help when they are most vulnerable and, as we have seen, being vulnerable makes people susceptible to suggestions and interference by people perceived to have more wisdom and better answers. It is easy when you are feeling afraid and uncertain to let someone else solve our problems for us. For our part, on the

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Chapter 6 Clarifying Who Owns the Problem 141

other hand, we sometimes find ourselves thinking it would be easier to just solve the clients’ problem ourselves rather than have to watch them struggle with it. This is a danger case managers seek to avoid.

Because we know the system and relate with empathy, our clients are likely to allow us to violate their boundaries and take over. People seek help usually where they feel an agency can be most helpful to them. They seek assistance from a place where the workers are perceived to have good answers. This is known in our work as a power differential. Case managers are perceived to be wiser and therefore can have considerable influence over how people decide to resolve their problems.

Determining who owns the problem and the extent to which people seeking our assistance can solve their own problems or at least aspects of their problems allows for more realistic boundaries where we do not interfere where a person is capable.

If the Client Owns the Problem

Let us suppose your client comes in and tells you that she cannot stand living with her mother anymore. Her mother is verbally abusive and rejecting. Your client is unhappy. Obviously, this client’s need for a pleasant home environment and her need to be appreciated by her mother are not being met. The client owns the problem. Does the mother own the problem? She does not appear to. This method of communicat- ing with her daughter seems to work for her. She shows no discomfort or guilt about any pain she might be causing her daughter. It seems to meet some need of hers to communicate in this way. The mother does not have a problem in this situation, as her needs appear to be met.

There are several important ways you can respond to your client’s situation. First, listen. Then, rather than providing a solution, be a resource to your client. Give her options. Tell her about services with which you are familiar that might be helpful to her. Ask her for her ideas. What is she looking for? What does she want to happen? Leave the final decisions up to her. In this way, you make sure that the client retains a position of power in her own life, and you act collaboratively. You are the expert on available services, but she is the expert on her own life.

Now let us change the story a little. Your client brings in the same problem, but she has an intellectual disability. The problem still belongs to her, but now you make a conscious decision to get a bit more involved and a conscious decision about the extent to which you will get involved. As a case manager or worker, there will be times when it is important to give more help than others. A wise worker will know how much to help and when to stand back. These are strategic decisions.

Deciding how much to become involved is important when the person has a problem with you. For example, a person may come into your office and tell you that he cannot stand the way you sit in front of a cluttered desk and talk to him. He claims he feels disorganized by your clutter and wants you to have your desk cleaned off when he comes in. In this case, you may make a conscious decision to let him own this problem because there is no way to clean the desk off in the middle of a busy day when you know he is coming in. You would thank him for his comments, give a word

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142 Section 2 Useful Clarifications and attitudes

or two about why that might not be feasible, and tell him you will continue to keep your office as it is for now.

On the other hand, another individual may be upset with you because you are always late. His need for punctuality is obvious; your being on time means to him that you are expecting him and that you value his time. His need is not being met. In this situation, you might decide to help own the problem. You recognize that you have been somewhat disrespectful. You can justify it with your busy schedule, but you also can do better. So you acknowledge the problem, thank him for his comments, and offer to be more punctual. You have made a conscious decision to become involved in the solution to his problem.

It Is Not Uncaring

Sometimes we feel guilty about not doing more. Sometimes others tell us that we should be doing more. After all, we are the person’s case manager. Why are we not extending ourselves further? Sometimes the clients themselves are the ones to accuse us of not caring or of being indifferent. Knowing who owns the problem and allowing that person to resolve it is not an uncaring action. In fact, you would never refuse to help a client simply because you determined the problem belonged to the client.

When you allow people to work on their own issues and problems, you respect their right to privacy and self-determination. In addition, you give them an important opportunity to grow and work on their own behalf. Solving one’s problems effectively is part of emotional health and maturity. To the extent to which clients are able, we want to encourage them to do as much for themselves as they can.

It Is a Strategic Decision

The extent to which you become involved in helping people solve problems that belong to them is a strategic decision. This is another difference between the profes- sional approach to relationships and a friendship you might have away from work. In the professional relationship with your client, you want to decide strategically how much help to give and the extent to which you will step in. The decision is based on your knowledge about the person’s abilities and about how this opportunity can be used to help your client grow.

A woman who is blind might need more help negotiating the transportation sys- tem than one who is depressed. A person who is illiterate and from a rural village might need more help working with the Social Security office in the city than would an urban lawyer. A child might require more support than an adult to carry out a personal decision.

The strategy lies in knowing your client’s strengths and limitations and tailoring your involvement to those factors specifically. In this way, you avoid taking over simply because that is the easiest thing to do or because you see all clients as helpless. Your involvement is just to the point the individual needs help or ideas and no further.

In certain cases, even though the client owns the problem, you may find yourself taking over and resolving it almost entirely alone. Suppose you are working with a single, 17-year-old girl, disowned by her family because of her pregnancy. She has just

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Chapter 6 Clarifying Who Owns the Problem 143

delivered her first child for whom she has made adoption arrangements. The child, however, is severely disabled with developmental issues. The doctors feel the care required by the child can never be undertaken by a 17-year-old girl living alone, and the prospective parents have now withdrawn their bid to adopt the infant. In this case, you work out arrangements for the care of the infant, solving the infant’s need for a safe, medically appropriate environment and solving the mother’s problem of what to do with a handicapped child she believed would be going to the home of another couple. In this case, you would consult with the mother throughout the process, possi- bly even taking her to see the facility where her baby will receive care, but you would handle most of the actual arrangements. If you did not understand the concept of who owns the problem, you might be tempted to ignore the mother in the process of solv- ing this problem. If the mother were older, married, having her second child with this handicap, and supported by her family (or in any number of different circumstances), your response and the extent of your involvement would change as well.

When the client owns the problem, carefully decide the extent to which you will be involved. Test your hypothesis about how much the person can handle alone. Be ready to take on more responsibility or give more responsibility to the individ- ual as you move toward a solution. Watch your involvement to be sure you are not obstructing the client’s opportunities to grow or to exercise self-determination and independence.

Be a Resource and a Collaborator

You will have at your fingertips information that can help the person solve a problem. You may have the names of agencies, phone numbers, contact people, and addresses for services. You will also be familiar with policies in various agencies and within large social service systems, such as child welfare and mental health. You will often be more familiar with the law as it pertains to the person’s situation. This makes you a valuable resource to a person attempting to arrive at a solution.

Bring the information and facts to the client, and then collaborate with the cli- ent on the solution. It is the clients who are most aware of which solution will work and which ones are impractical for their circumstances. Together, with your knowl- edge of the system and your clients’ knowledge of their personal lives and circum- stances, you will be able to construct a useful approach to clients’ problems.

If You Own the Problem

If you are having a problem, that is, your needs are not being met, you will understand that the resolution of the problem is ultimately your responsibility. This applies to personal problems, and it also applies to problems you might have in the course of your relationship with your clients. What if it is the client who is always late? When- ever the client is late, you find you are behind for the rest of the day. This is not the client’s problem. The client may find it perfectly acceptable to get to your office at approximately the time he is scheduled to see you. He may have scheduling problems

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144 Section 2 Useful Clarifications and attitudes

or punctuality problems; but in this case, he does not own this problem. You do. Your need to stay on schedule and see everyone you are scheduled to see before 5:00 p.m. is not being met. Therefore, you are the one who is responsible for bringing it up. Do not expect that others will guess there is a problem.

In bringing up a problem we are having with another person, we are asking for that person’s assistance in resolving it. Just as you make decisions regarding how much you will become involved in resolving someone else’s issue, your clients have the right to determine the extent to which they want to help you. It is conceivable that the client will see your point and make some changes. It is also possible that the client will decide that it will have to be your problem because it is preferable to be late for whatever reason or because being punctual is an inconvenience. There are ways to solve problems like this one; but for now, as the first step, you need to be clear about who owns this problem.

If You Both Own the Problem

Sometimes you both have a problem. Suppose a person needs evening appointments, and you work only during the day. Or perhaps a client wants to shout and yell about her situation, and you find that too unnerving to do a good interview. These are opportunities to negotiate. You, as the worker, have to be able to sort out in your own mind who owns what problem, and you must be able to initiate some negotiation around these issues.

When you both own the problem, you should not view it as a win–lose situation. If the client sees it that way, you need to point out other ways of looking at the situation. Perhaps he can see another worker who does work at night, or perhaps he can come in during the day sometimes and you can stay late sometimes. Maybe she can yell with less intensity, and you can overlook the rest of it. It might work to transfer the client to another worker, one whose schedule is better suited or one who can better tolerate the yelling. There are many ways to negotiate a solution. When you work on a solution collaboratively with the client, you provide that person with an important experience in problem solving. As the worker, you invite the client to join you in this effort.

Margaret had been ill with schizophrenia for a very long time. Rejected by most of the community and most of her strictly religious family, she found solace and sup- port among the workers in the mental health system. In the course of her illness, she had been hospitalized and knew the staff at the hospital well. She had encountered the various members of the crisis team and knew them too. She had a case manager whom she found supportive. Margaret found countless reasons to call workers within the system. Night and day she called with tiny questions, not so much because she could not resolve the problems herself, but because she found contact with these sup- portive people comforting. Sometimes she would call to ask what time she should go to bed. She might call to ask if she should eat one frozen dinner rather than another. Should she go out for a walk tonight or not? Should she buy a new pair of shoes or not?

Margaret’s incessant calling began to create a problem for already busy workers. They grew exasperated. Margaret had a need to feel their support, and the workers had a need to get things done with other clients. Finally, a solution was worked out

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Chapter 6 Clarifying Who Owns the Problem 145

with Margaret and all the workers in the system who regularly received calls from her. It was decided that a man on the crisis team who shared her religion and genuinely liked her would be the person she would call. When he was off duty, a backup person was designated. Margaret was then allowed only one call a day. She was to save all her questions for that one call. Everyone agreed to this plan.

Although Margaret tested the plan many times initially, everyone stuck to the agreement. Eventually, Margaret began to make the calls more meaningful, asking for help with real problems. Undoubtedly, this one call a day helped to sustain her and helped her to live more comfortably in the community rather than in an institution. It also allowed the workers to focus on other clients.

In this situation, both the workers and the client had a problem, and their needs conflicted. By collaborating on a solution, rapport was not lost, and both the workers and the client gained valuable experience.

Summary

Knowing who owns the problem is an important first step in working with clients. This allows us to understand who is ultimately responsible for resolving the problem. Once we recognize that many of the difficulties our clients bring to us are theirs, we need to determine the extent to which we will assist in problem resolution. Both the determination of who owns the problem and the decision to get involved are the first strategic decisions you make in your work with clients. Your involvement must be tailored to the clients’ strengths and capacities so that you do not take over where a person is competent or take from people the opportunity to grow and learn from their experiences.

For many, deciding that the clients own the problem can be seen as uncaring. In reality, you are not abandoning people with their problems. You are, instead, making decisions about how much individuals can do for themselves and where you will be most helpful. In the long run, we want people to be able to take some pride in the fact that they participated in solving their own problems and learn from that experience.

Exercises

These exercises can also be filled out online at CengageBrain.com.

Exercises I: Who Owns the Problem?

Instructions: In the following situations, identify who owns the problem. As you study each case, decide whether it is you, as the worker, who owns the problem; whether the client and perhaps the client’s family owns the problem; or whether both you and the client own the problem at the same time.

1. A woman you have placed in temporary housing is angered by the loud music of her neighbors. She appeals to you to do something about it. Who owns the problem?

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146 Section 2 Useful Clarifications and attitudes

2. You work at a victim/witness resource center where you assist the victims of crime to handle the emotional and technical ramifications of the crime before they go to court. The husband of a victim, a woman who was carjacked by a teenager one night, takes you aside and asks you to persuade his wife to drop the charges. He tells you confidentially that it would be better for his wife if “she didn’t have to go through this.” Who owns the problem?

3. The mother of a rape victim, with whom you have been working, calls and says that ever since the rape, her daughter has been crying and unable to eat or sleep. She tells you it is urgent that she know exactly what happened to her daughter, but that her daughter refuses to talk about it. She asks if you can tell her what happened. Who owns the problem?

4. You are talking to the victim of a violent crime in the emergency room. Her boyfriend barges in and demands to know “what’s going on.” Who owns the problem?

5. You have placed a woman in temporary housing after she left her home follow- ing severe abuse by her husband. The husband calls demanding to know where she is and tells you he will get his lawyer and sue you if you do not tell him. Who owns the problem?

6. You are working with a support group. One of the participants tells you on the side that another participant is monopolizing the group’s time with frivolous details and asks if you will do something. Who owns the problem?

7. Your client is going to court on his third DUI charge. The family of the woman whose car he hit calls your office before the proceedings because the article in the paper stated your client was receiving help from your agency in preparation for the trial. The family wants you to withdraw your services and advocate with the judge that your client be sent to prison and not to a rehabilitation center. Who owns the problem?

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Chapter 6 Clarifying Who Owns the Problem 147

8. You are arranging for housing for a woman who is in a homeless shelter. Her par- ents come to see you and ask you to see that she also goes to therapy. They tell you she has never “seemed right,” and they ask you to give them your opinion of her mental status. Who owns the problem?

9. You have developed a goal plan for a child. The parents agree with the plan, which involves summer camp and other recreational activities over the summer, all with a therapeutic program. The teacher calls to tell you that this child can hardly benefit from school and that sending him to camp is a waste of the tax- payer’s money. What he needs, she tells you, is therapy. Who owns the problem?

Exercises II: Making the Strategic Decision

Instructions: Following is a basic situation, with a list of scenarios in which the circum- stances surrounding the situation are different. Decide what you would do in each case.

Situation: Hannah recently went blind due to an accident with chemicals at the company where she worked. She is asking for a service plan that will help her regain some independence.

1. Hannah is a PhD chemist with the corporation where the accident occurred. She has received a huge settlement from the corporation’s insurance company. The corporation has said she can come back to work if she can be retrained in some way, possibly with computers. Hannah has a supportive husband and many close friends. How do you help?

2. Hannah was a custodian at the small chemical engineering company where the accident occurred. The company had little insurance, and it has no interest in hir- ing her back for any reason. The company did give her $5,000 at the time of the accident, and the hospitalization plan and workers’ compensation helped pay the initial medical bills. Hannah lives alone and has few friends. How do you help?

3. Hannah has an intellectual disability and worked as a custodian at the company where the accident occurred. The company gave her $5,000 at the time of the accident, and the hospitalization plan and workers’ compensation helped pay the initial medical bills. Hannah lives with her parents, who are very supportive, and she has two older siblings who also give support. The family has been working with Hannah to help her decide what to do next, and they have found a place where she can answer the phone and give standard information. This company is delighted to have a real person to do this, as the answering machine option seemed too impersonal. Hannah will need some training. How do you help?

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148 Section 2 Useful Clarifications and attitudes

4. Hannah is a student working on a chemical engineering degree. She worked part time to pay her school expenses at a large chemical corporation. She wants to remain in school. Her family is supportive of this, but they live in another state. Hannah’s roommates seem hesitant about her returning to live with them in their downtown apartment now that she is blind. How do you help?

5. Hannah is a student working in a small chemical lab while completing a chemi- cal engineering degree. She wants to remain in school. Her family is supportive of this, but they live in another state. Hannah wants a seeing-eye dog, has a land- lady who is afraid of dogs but who might accept one, and needs to learn how to negotiate the town and the campus as a person who is blind. She has numerous supportive friends. How do you help?

6. Hannah is a student working on a chemical engineering degree and doing a chemical engineering internship at a chemical plant near the college. She wants to remain in school. Her family is supportive of this, but they live in another state. Hannah was using this job to pay for her education. Now Vocational Rehabilitation will help, but Hannah must fill out countless forms. Hannah is depressed and frightened by her blindness and spends days at home alone. How do you help?

7. Hannah had a fairly ordinary chemical technician’s job at the company when the accident occurred. She and four other people were blinded by the accident. Hannah has told you she wanted a lawyer while she was still in the hospital, and she also feels the group should meet regularly to talk about the accident and their anger. The others have agreed. Hannah tells you of the state office of services to the blind and wants help connecting to that office. How do you help?

8. Hannah had a fairly ordinary chemical technician’s job at the company when the accident occurred. The company offered to pay all her medical benefits and a small stipend to support her while she trained for another kind of work, not to exceed 5 years. Hannah lives alone and has few friends. She makes it clear to you that she is not interested in receiving any help from you. She rejects services that you know could help her to begin training and asks you to leave her alone. How do you help?

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Chapter 7 Identifying Good Responses and Poor Responses 149

Identifying Good Responses and Poor Responses

Introduction

This chapter provides some concrete examples of good and poor responses. Those called “poor” are poor in the sense that they tend to block communication and prevent the worker from hearing what is really important. The examples of poor responses are followed by examples of good or constructive responses that encour- age another person to talk and feel comfortable doing so. Like learning to drive a car, we learn step by step the ways to structure responses that will facilitate good communication.

It is not enough, however, for you to look at these responses and do the exercises. You will soon build a skill in identifying which responses are inadequate and which actually enhance the communication, but this will not teach you to automatically use good responses rather than poor ones. What you are seeking to do is create a conver- sation between you and your client that flows so that the client feels encouraged to talk, safe about divulging their issues. This chapter is a start, but there is no substitute for practice. In later chapters, you will learn to use constructive responses with more understanding of how they promote rapport and clarity. Even this understanding, how- ever, will not help you to make an automatic response that is therapeutic if you have not practiced.

This chapter clarifies which responses are most likely to promote rapport and which are most likely to promote withdrawal and defensiveness.

C h a P t e R 7

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150 Section 3 effective Communication

Communication Is a Process

We are inclined to think of communication as messages we simply send to another person. In an exchange that person may respond with a message of her own. We know what we mean when we communicate and usually assume that everyone else does as well. If we are misunderstood or our message is not clear when it is received we tend to blame the other person. What got into him today? Why is she overreacting that way? What did he mean by that response? It doesn’t make sense?

Likewise, we assume when someone speaks to us that we have pretty much received his message as it was intended. When something people have said doesn’t make sense to us we assume they did not frame their message well or their way of communicating this message is garbled.

This is a simple way of looking at communication. A speaks to B and B responds and everyone understands the verbal messages being exchanged. Communication is more than that and for our purposes, where we are engaged in evaluations and empathic interactions, understanding communication on another level is important.

Communication Is an Ongoing Exchange

When we are talking to another person we are sending and receiving messages, often at the same time, in a rapid, ongoing process. For example, you might give your client information about where she can get help with childcare at the same time she may be giving you a look that lets you know she tried those people and did not like them. You might talk about the need to be on time for appointments while your late client shrugs his shoulders. In talking to one another messages are often more than words and the exchange involves both parties in receiving and sending communications during the encounter. You might be explaining a policy to a person who is interrupt- ing you to complain about a different policy. Communication is rarely a neat exchange where A talks, B listens and fully understands the message, then B responds and A listens and fully understands the response.

Communication Involves Meanings

When the client made a face about the agency you suggested for childcare how did we know what she meant? In this case we assumed she was making a face to indicate she did not like this particular agency. What if, however, she meant her raised eye- brows and skeptical look to mean she was surprised you would go to all this trouble to help her? It can happen when we speak as well. You might say to someone, “I am sorry you had to go through all that traffic to get here” and the other person hears a differ- ent message that you are really sorry the person is late and holding things up.

This is especially true when two people involved in a verbal exchange, what we call a conversation, are from different backgrounds, have different cultures, different levels of education, or different life experiences. We can misunderstand each other when one of us is having a bad day, does not feel well, or has different expectations for the encounter.

For example, you might think you are helping your client by telling her when and where she can catch the bus home and after the day she has had she may decide

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Chapter 7 Identifying Good Responses and Poor Responses 151

you are trying to get rid of her. You might explain your policy about canceling appoint- ments and your client may think you see him as the kind of person who would not cancel but would just not show up when he has an appointment. A person from an Asian country may approach you to drop out of group and when you try to talk about how you could make the group work better for him, he feels you are hurt by his desire to drop out and quickly agrees to stay, nodding agreeably when he really intended to leave the group. You may leave this encounter believing you have solved his issues with group and he may leave upset that he still is committed to coming.

Communication Is Transactional

Communication is transactional, according to Adler, Rosenfled, and Proctor, 2013. They describe it this way: “(C)ommunication is a dynamic process that the par- ticipants create through their interaction with one another” (p. 11). They go on to describe communication as “Something we do with others” (p. 11) or “like dancing” (p. 11) where partners can communicate together beautifully or may instead miss cues and misunderstand messages. This process comes in two parts: First, if we communi- cate what we mean to communicate and we have a good partner who accurately hears the meaning we intended and second, if we hear other person’s response and accu- rately grasp the meaning they intended we have great communication.

If, on the other hand, we know what we meant and the other person hears another meaning and responds to this different meaning and we are confused by this and do not understand their message in response we do not have good communica- tion. When we talk to others we are together creating an ongoing dialogue. Like a dance, this communication can flow beautifully or someone can figuratively step on someone’s toes. The dialogue we create with our communication partner is unknow- able before we start. The result of this communication can be positive, where your communication partner leaves feeling positively about you and your agency. How- ever, in spite of your best intentions your communication partner may go away angry and hurt, feeling misunderstood.

What we know is that unfortunate communication can happen when we do not think carefully about the message we wish to send and check with our partner to be sure we understand the meaning he or she wants to convey to us. You will be the partner in countless encounters with clients and other professionals. The focus in the next few chapters is to give you the skills you need to minimize the possibility that communication will go awry.

Twelve Roadblocks to Communication*

Dr. Thomas Gordon’s (1970) Parent Effectiveness Training provided a useful frame- work for looking at types of communication with the purpose of finding those responses that encourage a person to talk and feel valued and those that block the

*Adapted with permission from Parent Effectiveness Training, by Thomas Gordon. Copyright © 1970 Random House, Inc.

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152 Section 3 effective Communication

communication and discourage disclosure. In his work he outlined 12 specific ways we often block good communication, setting up barriers to real understanding and dialogue. I have adapted these roadblocks to fit the kind of poor communication that sometimes happens in the human service setting. These responses are not helpful in talking with other people. They serve to obstruct rapport and block any constructive resolution of the problem, and they often serve to make our clients feel inferior or demeaned.

In the examples of poor responses provided in this chapter, notice the implied superiority of the worker. Individuals who come seeking assistance already feel unsure of themselves and uncertain about what to do. Workers who come across as all-knowing or judgmental are not helpful. An attitude of superiority—giving people the sense that the worker is “talking down” to them—is harmful to the relationship and makes real communication and rapport difficult.

Notice how hard it would be for a person to trust and be open after hearing the poor responses. What does one say to someone who appears to be patronizing? Most people stop talking or resort to pleasantries after that, and real communication is blocked. Why continue being open if the responses are not empathic?

In addition, you will find that many of the responses are well meaning. They may sound to you like the kind of thing one acquaintance might say to another, but they are not helpful in the case management setting where we want to encourage a person to feel comfortable talking freely, often about difficult subjects. Let’s look at some examples of such negative responses.

We look at these poor responses in order to begin to distinguish what we might say that would inadvertently block a constructive relationship between you and your client. It is helpful for you to see these responses, imagine how they might sound to someone seeking help, and recognize how they could stifle further discussion.

Ordering, Directing, Commanding

The first roadblock involves giving the person an order or command. The assumption made by workers who do this is that they have all the correct answers or all the best solutions and ideas. There is no dialogue or collaboration. In the following examples, the workers take charge without including their clients:

• “I don’t care what anyone tells you! You have to go see that lawyer!” • “Go right back over to the courthouse and get those forms!” • “Leave your house and come right down to the office.” • “Look, just go over and apply for the job.”

Warning, Admonishing, Threatening

Warning of consequences if the person does something is the second roadblock. Workers who do this do not want their clients to follow certain lines of action, often out of concern for the client. Rather than discuss their clients’ inclination to act in a particular way, they warn the client instead. In this next series of responses,

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Chapter 7 Identifying Good Responses and Poor Responses 153

the workers here sound as if they know better what is good for the client than the client does:

• “If you take that suggestion, I think you will be sorry!” • “You’d better not do that.” • “I can tell you from experience that something like that won’t work!” • “You won’t get your medications if you don’t attend group regularly.”

Exhorting, Moralizing, Preaching

The third roadblock is telling clients what they should or ought to do. Again, such workers display the belief that they have all the answers. In several of the responses that follow, you can hear the workers imposing their own moral values on their clients. Listen to the “shoulds” and “oughts.” Workers using these two words speak as though what they are saying is a universal given rather than a personal choice or value.

• “You should know that doing that is wrong!” • “You shouldn’t think like that.” • “You ought to see a counselor.” • “You ought to be more concerned.”

Advising and Giving Solutions or Suggestions

Telling clients how to solve their problem is a fourth roadblock. When workers believe their clients have nothing useful to contribute to the resolution of a problem, they will make unilateral decisions without their clients’ input. Some of the follow- ing responses indicate the worker’s exasperation with the person. Workers who tell people how to solve their problems believe that their way of seeing the clients’ prob- lems is the only way to see them. The clients are treated as though they are hapless or inadequate for not seeing their problems that way as well. Here are some worker responses that illustrate the point:

• “With your husband? We’ll set up marriage counseling and you can tell him what you think in those sessions?”

• “I think you just stop seeing this person today.” • “Here is what you need to do. Get your diploma and go on to college.” • “If you listen to yourself, clearly the answer is for you to stop hanging around

with them?”

Lecturing, Teaching, Giving Logical Arguments

The fifth roadblock involves trying to influence with facts, arguments, and logic. In this next series of responses, the workers sound as if they believe their clients are incompetent. Only the workers know the whole picture. These responses by workers do not encourage real discussion of clients’ feelings and problems:

• “I am going to give you the facts about domestic violence. If this doesn’t change your mind, I don’t know what will.”

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154 Section 3 effective Communication

• “Look at it this way, the longer you put up with this, the more she gets away with it. People always try to get something for nothing. It is human nature. Your task is to stop it now.”

• “Now what you need to do is call the police. That will absolutely circumvent any action on their part and free you to move to another location.”

• “Now look, you have two choices. You can either stay or leave. That’s what you have to decide. My vote is with leaving because that ends the problem perma- nently.”

Judging, Criticizing, Disagreeing, Blaming

Making a negative judgment or evaluation of clients is the sixth roadblock. In the responses that follow, the workers see themselves as judges of their clients’ behavior. Instead of being supportive, these workers are grading their clients’ behavior. Their responses can only serve to demean a person who is grappling with problems and feels unsure. Here are some examples of such demeaning worker responses:

• “You aren’t thinking clearly.” • “You’re very wrong about that.” • “I couldn’t disagree with you more.” • “Your plan is faulty because you never did your research.” • “I think you could have handled that better.”

Praising, Agreeing

The seventh roadblock is offering a positive judgment or evaluation, or agreeing. Sometimes workers really cannot tolerate the pain clients express about certain situa- tions. In the sample responses that follow, the workers are certainly well-meaning, but their responses cut off any meaningful discussion or further exploration and relieve the workers from having to deal with the real pain their clients might want to talk about.

• “Well, I happen to think you did just fine.” • “You’ll figure this out. Don’t worry.” • “It will all work out for the best. You’ll see.” • “You’re smart enough to know what you need to do.” • “You’re bright. You’ll figure it out.”

Name-Calling, Ridiculing, Shaming

Making clients feel foolish is the eighth roadblock. Perhaps workers who give responses like those that follow are just fed up. They may tell themselves they have a right to express such degrading sentiments because they put up with so much from their clients. Only very untrained and unprofessional workers would ever resort to name-calling, but when it happens, the workers generally try to excuse what they

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Chapter 7 Identifying Good Responses and Poor Responses 155

have said by claiming they have endured long-term disgust or exasperation. Here are samples of responses from exasperated workers:

• “You’re just an idiot if you do that.” • “Okay, you had to go and do it your way. You’ll see.” • “What you’re doing is totally ridiculous!” • “You act like you never finished first grade!” • “So be a fool. It won’t get you anywhere.”

Interpreting, Analyzing, Diagnosing

The ninth roadblock consists of telling clients what their motives are, or analyz- ing their actions. Sometimes, in order to feel vastly superior to their clients, work- ers will engage in surprise revelations. They often do this to show their clients that they know more about their clients’ inner conflicts than the clients do themselves. In the responses that follow, the workers are informing the clients of their motives and underlying intentions, as though their clients lack self-awareness.

• “You’re just upset because you haven’t heard from the lawyer.” • “I think you really wanted to press charges but you just can’t admit that.” • “You don’t really believe that about her. I know that you are just saying it be-

cause you wish it were true.” • “What you really mean is that you don’t want to see him anymore.”

Reassuring, Sympathizing, Consoling, Supporting

Trying to make people feel better or trying to talk them out of their feelings is the tenth roadblock. The following responses are offered as a way of comforting clients, but they serve to cut off real discussion of painful feelings. Telling clients you know how they feel or you understand what they are feeling is not convincing, even if you have had similar experiences. Listening to the feelings is better than cutting them off. Following are responses by workers that tend to cut off clients’ expression of their feelings:

• “You’ll feel better in the morning.” • “All new mothers go through this at one time or another.” • “Don’t worry. Things will work out.” • “You’re not alone. Everyone feels the way you do from time to time.” • “I understand how you feel.”

We will examine this tenth roadblock further below, looking at why this kind of comforting reply is not always helpful.

Probing, Questioning, Interrogating

The eleventh roadblock concerns trying to find motives, reasons, and causes. Clients do not always tell their concerns in logical sequence, and there are good ways for workers

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156 Section 3 effective Communication

to go back and fill in the gaps without sounding as though they are prying. In the fol- lowing examples, however, the workers are actually prying into their clients’ motiva- tions and intentions—areas the clients may not be fully aware of or ready to discuss:

• “Just when did you start to feel this way?” • “Why do you suppose you went there that night?” • “Do men ever tell you that they feel violent toward you?” • “What were you really trying to do when you saw her?” • “So why were you so intent on going there with her?”

Withdrawing, Distracting, Humoring, Diverting

Trying to get clients to focus on something other than the problem is the twelfth roadblock. Sometimes workers are overwhelmed by what their clients have told them. They may feel helpless to make a real difference or offer substantive help. Perhaps they realize that all they can do is listen, but listening is painful and difficult. To save themselves from these uncomfortable feelings of inadequacy and helplessness, work- ers may resort to responses like the ones that follow:

• “Just forget about it!” • “C’mon! How are things at church?” • “Let’s see, you could always run over him in your car.” (chuckle) • “Let’s turn to other things in your life.” • “You’re upset. Why don’t we talk about your cat?”

Using the Phrase “I Understand” It is tempting to want to comfort people who are upset with the phrase “I understand.” Sometimes workers say to clients, “I under- stand how you feel.” Worse yet, a worker might say, “I understand how you feel. That happened to me once.” Often, however, this sounds really trite. Most of us can never fully understand exactly how a client feels.

Another phrase some workers use is “I understand, but . . . ” This phrase is even worse. In addition to the fact that we cannot fully understand what a client is experi- encing, the but in the phrase tends to negate the person’s very real feelings and push the worker’s perspective instead. Make it a point to refrain from soothing clients with phrases such as “I understand” or “I understand how you feel,” and certainly refrain from saying, “I understand, but . . .” Instead, you will learn to feed back to the other person the feelings you believe that person is experiencing, giving the other person a much better sense of being understood.

Useful Responses

In this third section of the book, you will be looking at and practicing responses that enhance communication. Following are several categories of responses that you may find useful as you construct answers to the exercises in this section of the book.

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Chapter 7 Identifying Good Responses and Poor Responses 157

Learning to structure good responses is a little like learning to drive a stick-shift car, rather than an automatic one. For years your communication responses to other peo- ple have been automatic. They probably worked because you were in relationships other than professional ones. In our friendships and family relations, people commu- nicate in shorthand. These relationships are generally positive and familiar, so others do not need to guess what it is we are saying.

Now, as a professional, you are responsible for creating an environment that makes people feel comfortable and safe enough to be open. Clients will not know you very well, if at all, when they come to see you. Therefore, you are in charge of communicating in a way that builds rapport and collaboration in regard to the clients’ problems. This means that at first you will have to think carefully about how you are going to respond before you do so.

The good response examples that follow contain openers that you can lift right off the page to get you started on the exercises you will find in later chapters on com- munication. Use these initial phrases to structure constructive responses. Gradually, as you practice, you will begin to sound more like yourself, and your responses will not seem as rehearsed. At first, however, you need to practice effective ways to answer what another person has said. Using the responses provided here will help you to get started in this process.

Ways to Start Responding to Feelings

When people are talking to you about something that involves an emotion or feeling, it helps them to feel comfortable and understood if you can identify their feeling and say that back to them. This is part of practicing empathy. When you do so, it is best to structure a single sentence and say nothing more. Anything that you might add to this could take the conversation away from where they are and over to something you have introduced.

In addition, do not confuse the person by adding more than one feeling. You might say You must feel so hurt and that would be fine. If you said You must feel so hurt and betrayed your message is less precise and somewhat confusing. Be very careful about this. Here are some useful openers to use when you respond to feelings:

• “That must have made you feel . . .” • “You must feel . . .” • “You must have felt . . .” • “That must have been . . .” • “That must be . . .” • “It sounds like you’re really feeling . . .” • “How [sad, upsetting, wonderful] . . .” • “Sounds like you really feel . . .” • “You must be . . .” • “You must feel so . . .” • “It sounds like you felt . . .”

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158 Section 3 effective Communication

Ways to Start Responding to Content

There are times when you might indicate you heard accurately by responding to the content of what someone has said. In this way, you confirm that you are hearing what the person has told you and confirm for the person how important the details are to you.

• “So, it’s important to you that . . .” • “You’re really concerned about . . .” • “So you were [he/she was] . . .” • “Right now you want . . .” • “So, in other words, . . .” • “So what happened was . . .” • “So you decided to . . .” • “You really need . . .” • “You’re hoping that . . .” • “It sounds like they [he/she] . . .” • “So they [he/she] just . . .” • “So you just . . .”

Ways to Start a Closed Question

There are times when you need facts or specific information. Questions that require only a single answer are often referred to as closed questions. Here are some ways to start a closed question.

• “What is your . . .?” • “Where did you . . .?” • “Who is . . .?” • “When were you . . .?” • “Where do you . . .?”

Ways to Start an Open Question

When we are listening to clients give background about their concerns and problems, our questions need to be more open to solicit the information the individuals believe is significant. Here are some ways to start an open question.

• “Can you describe . . .?” • “Can you tell me a little bit about . . .?” • “Could you talk about . . .?” • “Could you describe more about . . .?” • “Can you tell me a bit more about . . .?” • “Can you fill me in on . . .?” • “Could you clarify that a little bit more for me?” • “Can you tell me something about . . .?” • “Could you say something about . . .?”

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Chapter 7 Identifying Good Responses and Poor Responses 159

Ways to Start an I-Message

There will be times when you are concerned about something the client has done or said. You may be worried about something the client intends to do or something the client has not done. In the roadblocks to good communication earlier in this chap- ter, many of the ways workers brought up their concerns were confrontational and superior. A better way to bring up our own concerns is to indicate that these concerns belong to us. We do this by using the word “I” first. These responses can consist of several sentences and should sound tentative rather than judgmental or decisive.

• “I feel . . .” • “I’m just concerned that . . .” • “I’m wondering if . . .” • “It appears to me that . . .” • “I need to understand . . .” • “I’m not clear about . . .” • “I need to kick something around with you.” • “I’m having a problem with . . .” • “I’m uncomfortable that [with] . . .” • “I guess what worries me is . . .” • “I think what I’m most concerned about is . . .”

Notice in these responses how tentative they are. The worker is “wondering’ about something. The worker uses terms like “I guess” or “I think.” This leaves the discussion open for the other person to respond.

Useful Ways to Begin a Firmer I-Message

There are times when you need to act on behalf of clients. Another person may be unintentionally interfering in some way. This may call for an invitation to help, and that invitation must be worded in a way that is more authoritative, but not offensive. Here are ways to be clear about what you want or need:

• “I need you to . . .” • “It would be very helpful if . . .” • “I wonder if you could help us by . . .” • “Could you . . .” • “Would you please . . .” • “We need your help to . . .”

Always use please and thank the other person when you make these requests.

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160 Section 3 effective Communication

Ways to Show Appreciation for What Has Been Said

When clients bring something to your attention that is of concern to them, it is a good idea to let them know you appreciate what they have to say. Sometimes they are tell- ing us about something we or our agency has done that bothers them. Nevertheless, it is always a good idea to show appreciation. Here are some ways to start appreciative responses.

• “Thank you for bringing this up.” • “It was good of you to tell me about this.” • “I appreciate your thoughts about this.” • “Thanks for telling me.” • “It’s helpful to me to know this.” • “Thank you for letting us know.”

Specific Questions Useful in Beginning to Disarm Anger

When clients express anger with us or our organization, it is not constructive to argue with them. Arguing undermines your work with the person and inflames the situation. Instead, showing a genuine interest in what they are telling us is better for maintaining a good relationship. Here are some questions to ask that indicate a genuine interest on your part. By using these responses, you indicate that you really want to understand the problem the client is experiencing with you or your organization.

Do not ask the person all of these questions; one or two of them will indicate a real willingness on your part to grasp the issues and make it safe to discuss issues the client may have with you or the agency. Too many questions can make the client feel he or she is being interrogated.

• “How did I [we] offend you?” • “What did I [we] do?” • “When did I [we] do this?” • “How often did I [we] do this?” • “What else about me [us] upsets you?” • “What might I [we] do to clear this up?” • “Can you tell me more about what happened?”

Examples of Ways to Agree When Practicing Disarming

When we are not acting in a professional capacity, it is common to feel very defensive when someone criticizes us. Usually, however, there is a kernel of truth in what the other person is expressing even though it might seem exaggerated or trifling to you.

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Chapter 7 Identifying Good Responses and Poor Responses 161

Here are some responses you can use to let clients know that you can see and accept the truth in what they have told you.

• “I’m sure I could do better at times.” • “We probably could do things a bit differently.” • “There are people who have had more experience than I have.” • “It may be that we (I) could do things differently.” • “Probably we’re not always aware of these problems.” • “It is very possible that (I) we overlooked this.” • “I certainly can be forgetful at times.”

Sample Response When You Cannot Change

After a heated exchange, an angry client may be expecting that you will change the way you do things. Sometimes you are not able to change things. Maybe you are blocked by the law or because of how a change would affect other clients or staff. When that happens, you need a pleasant way to let the person know you cannot make the requested changes. Here is an example of what you might say:

• “I understand your point. We’re going to have to continue this way for now, but it was helpful to hear your concerns.”

Sample Response When You Find You Can Compromise

At other times, clients make useful suggestions, and the requested changes can be made. Here is an example of how you might respond in such a situation:

• “I think you have good ideas and there are some ways we can solve this problem.”

Ways to Start Collaboration

Nothing really useful can happen for clients if there is no collaboration. Even when clients will be doing most of the work, the word we can soften this fact and create a team approach to the problem. In this way, you let clients know they can trust your intention to be supportive without taking over and forcing a solution. Collaboration has another useful purpose. When done well, it prevents your giving the impression that you feel superior and that you see clients as being helpless and inadequate. Here are some ways to begin collaboration:

• “Perhaps we can . . .” • “Maybe we can [could] . . .” • “Let’s [look at this together, look at your options, see what we can find out about this].” • “We can [could] . . .” • “Why don’t we . . .” • “We might . . .” • “You and I together can [could] . . .”

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162 Section 3 effective Communication

Ways to Involve the Client in Collaboration

Sometimes clients do not participate. You make suggestions, and the clients simply go along with them. If this happens often, the clients are not collaborating or participat- ing in solutions to problems they own. There are ways to help people become more involved. Here are some examples:

Start with an I-Message

• “I’m wondering if we . . .” • “It occurs to me that we . . .” • “I am just thinking that perhaps we . . .” • “I guess what concerns me is . . .” • “I think I am worried about . . .”

Finish with a Question or Comment That Invites Collaboration

• “What do you think?” • “I’m wondering what you think.” • “What thoughts do you have?” • “Maybe you see it differently.” • “You probably have some ideas too.” • “But it’s important to me to know how you see it.” • “But I think what would really be helpful is to hear your ideas about it.” • “How do you see it?” • “What are your suggestions?”

False Praise versus Positive Feedback

Earlier in the chapter in the discussion of roadblocks to communication, some exam- ples of ways workers might praise clients were presented. These statements do not contain real information clients can use. It is all right to give people positive feedback, but not to say something trivial that contains no information clients can use in the future when they encounter difficulties. When you give positive feedback to a client, structure what you have to say to include information the person can use.

For instance, suppose a client worked on and solved a tax problem. Rather than just praising the fact that she solved the problem, it might be better to point out information about the client she can use in the future. Here is an example of how to do that.

“I thought you handled the people at the tax office very well. You asked the right questions and didn’t get flustered, and I think that really helped to resolve the problem.”

Now the client has been given feedback that identifies traits that might be helpful to her in the future: She seemed capable of talking to others and asking the right ques- tions, and she was able to communicate without becoming flustered. This kind of response is much better than one like, “See how smart you are?”

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Chapter 7 Identifying Good Responses and Poor Responses 163

Following is another example of good feedback that contains useful information for the client.

“I think it has taken real determination for you to stay sober this long. I’m just impressed with how you have managed an entire week like this.”

Again, this is a statement that gives the client useful information: The worker believes the client has “determination.” This is something he can rely on in the future when times are tough. Thus, such a response is better than something like, “Good for you! You’re still sober!”

Minor Problems

The following examples demonstrate some of the minor problems you might encoun- ter during your communication with your clients.

Minor Problem One. You assess your client’s feelings incorrectly. For instance, you might misinterpret a client’s underlying feelings and thoughts. You might say, “You must have felt sick when you saw what the accident did to your car.” The client might respond by telling you she really did not feel sick. Instead, she was angry—furious, in fact—at the other driver who stood there and screamed at her. It is always possible that clients may correct you in this way. This is positive. It allows people to make you aware of what they are really feeling and thinking, bringing you much greater clarity.

Minor Problem Two. Your mind wanders. At times you may not be listening atten- tively. Something has happened at home; you just finished handling a personal prob- lem; or you hoped to go home before 4:00 P.M. and now it is 5:00 P.M. and this new issue may take some time. Your mind leaves the immediate situation and wanders to your personal concerns. Of course you do not want this to happen often, but it will happen. If you are practicing good body language, sitting in a way that communicates interest and attention to the client, these momentary shifts in your focus will not be damaging to your relationship.

Major Problems

The following are examples of major problems that can occur during your communi- cation with your clients that are not at all useful.

Major Problem One. You cannot wait to pass judgment. Sometimes workers listen to clients, but their minds are full of judgments they want to make about what the people have said. Rather than truly listening, these workers are judging the clients in regard to how well the clients handled their situations, whether the clients were smart or stupid, and whether the clients were on top of things or lax in taking care of the situations.

Such workers cannot wait for clients to be quiet so they can give an authoritative judgment. Rather than listening, these workers are preoccupied with what they plan

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164 Section 3 effective Communication

to say in response. This is unprofessional listening. We might do this with our friends and relations, but it has no place in a professional relationship.

Major Problem Two. You ignore the client’s feelings. Another way to miss the important issues is to focus entirely on content and never hear the meaning this situ- ation has for the client. In other words, you fail to practice empathy. Instead of com- menting, “How difficult it must have been,” the worker goes on about the actual details, “So actually this happened in town.” There is a place for this kind of listening, listening to content, but when you do this exclusively and never talk about feelings, important opportunities are missed for healing and building rapport.

Major Problem Three. You cannot wait to offer the solution, to give advice. Oppor- tunities are lost for establishing rapport and understanding. If the worker does not acknowledge the feelings a client is expressing and rushes to a solution, the person may not feel they were really heard. Some workers rush right past the feelings to the solu- tions. Rather than saying, “You must have found that so painful,” such a worker would say something like, “Well, you’ll need to see a lawyer about this. There is a good one around the corner that we use a lot, and I can probably get you in to see her in the next day or so.” Anyone can tell a client he needs a good lawyer. Only a very good listener is able to respond with empathy to the underlying feelings present in the client’s story.

Major Problem Four. You feel an overwhelming need to get to the bottom of the problem and solve it. You feel the client is expecting you to do just that and you are trying to figure out the solution and so you begin to ask a lot of closed questions, one right after the other. “Did you ask your aunt about it? Did she tell where your cousin is? Did you try to reach your cousin? Is there a reason your cousin did not call you directly? Where do you think your cousin is?” You ask and the client answers and in your head you are trying desperately to construct a solution for the client. In this case it would have been better to start with one open question, “Tell me more about your cousin’s leaving,” and follow up with other open questions that seek what the client is thinking would be the best solution here.

Summary

This chapter has provided you with a sense of how good and bad responses sound. Good responses are constructive responses that promote rapport, facilitate collaboration, and build trust; poor responses block rapport, understanding, and further exploration. Knowing how these two different kinds of responses sound, however, and actually using them are two different things. To become proficient, you must practice.

In each chapter in this third section of the book, different types of responses are discussed along with what they are intended to accomplish in a therapeutic sense. Each chapter contains a series of exercises. To do these exercises, at least

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Chapter 7 Identifying Good Responses and Poor Responses 165

initially, turn back to this chapter and refer to the examples of useful responses pro- vided in it. Use these sample openers as a springboard to developing constructive replies of your own.

Video Example

To view the videos that accompany this book, go to CengageBrain.com.

• “Case Management with an At-Risk Individual”—To see these responses in an actual interview you can view the video segments online. Those segments (1, 6, 10, 12, 14, 16) where case managers are talking with their clients demonstrate how these techniques are applied when talking to other people.

Exercises

These exercises can also be filled out online at CengageBrain.com.

Exercises: Identifying Roadblocks

Instructions: Following are various scenarios illustrating workers’ responses in a variety of situations. Examine the responses in each case and decide whether the worker is blocking communication or enhancing it. Do the worker’s responses cut off further communication from the other person or seem to encourage the person to con- tinue? Circle your answer after each vignette.

1. Carlos is afraid his mother is dying. He is talking to the worker in the hospital emergency room about an “attack” his mother seemed to have when she could not breathe and turned blue. She was brought to the hospital in an ambulance, and Carlos is waiting to see whether she will be all right. He is distraught. The worker says, “You certainly did the right thing to call the ambulance. Don’t worry she’ll be all right. We have very good doctors here.” Can Carlos continue to ex- press his anxiety freely?

Enhanced Blocked

2. Anita and her family moved, and her parents feel Anita is not adjusting well to the move. Anita wants to return to her old school to be with her friends. Her parents ask the worker to talk to Anita about her desire to return to her for- mer school. Anita talks about how strange the new school is and how much she misses her old friends. The worker replies, “Tell me something about your friends where you used to live.” Can Anita continue to tell the worker what she misses about her old school?

Enhanced Blocked

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166 Section 3 effective Communication

3. Elvita has decided to leave an abusive relationship, but she feels guilty leav- ing her abuser’s children behind. She talks about how she knows that once she leaves, she cannot have any more contact with the children; and she is worried about how that will affect these children whom she has come to love and wants to protect. The worker asks, “Just when did you start to think of these children as if they were your own?” Can Elvita continue to discuss her concerns about her abuser’s children?

Enhanced Blocked

4. Ed suffers from chronic mental illness and needs medications to maintain his mental health. Recently he went to several workshops on the use of supple- ments and vitamins to maintain mental health. He wants to discuss these ideas with his worker. He makes it clear that he is not really thinking of going off his prescriptions, but he would like to consider trying these supplements in addition to his medication. The worker says, “It sounds like you really got a lot out of that workshop.” Can Ed continue to explore the things he learned at the workshop with the worker?

Enhanced Blocked

5. Shawna wants to go to college. She attended a poor rural school where most of the students do not go on to college. Her scores for the entrance exams were very poor in math, and she feels unsure that the developmental course being of- fered to her at the college will really help her catch up. She seems anxious and uncertain. The worker says, “You don’t seem to quite understand what develop- mental courses are. Look at the number of people who take them. Look at how many of those people finish school. You need to think about this a little less emo- tionally.” Will Shawna feel comfortable in the future talking about her concerns about going to college with this worker?

Enhanced Blocked

6. Ada is very upset over the divorce settlement. She got the house and the chil- dren, but very meager support and only a small amount to go to school to up- grade her skills. As she speaks with the worker, she is crying and expresses the belief that she cannot make it. The worker replies, “Look, get another lawyer. You’re going to have to just face the fact that you had a lawyer who wasn’t serv- ing you. Go back to court! Reopen the case! Make a stink!” Will Ada be able to talk about her divorce with this worker?

Enhanced Blocked

7. Lindsey is an alcoholic and tells her worker she wants to stop drinking but doesn’t know how. She tells the worker that for a while she stopped drink- ing while she was going to AA meetings, but she stopped going and began to drink again when she reunited with old friends. The worker says, “Here’s

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Chapter 7 Identifying Good Responses and Poor Responses 167

the bottom line. You either do what you need to do or you don’t. Don’t come in here crying about how you stopped AA. That’s your responsibility to go there—so go!” Can Lindsey continue to talk about options for not drinking with this worker?

Enhanced Blocked

8. Reynaldo just lost his job and is frantic about how he will pay the rent. He talks to the worker about how he will pay his rent and whether he will be eligible for unemployment. In the course of the conversation, he mentions his fear of going home to face his wife. He does not believe she will understand. The worker says, “Well, you’re mostly upset because you’re afraid of your wife and what she’s go- ing to say about this.” Will Reynaldo want to continue to express his worries with this worker?

Enhanced Blocked

9. Tonda is discussing her need for help with a depression that, she says, started several months ago. She talks about the amount of time she has missed at work and how it has reached a point where she sleeps most of the day. The worker says, “Tell me a little bit about what was going on when this all started.” Can Tonda continue to discuss her depression with this worker?

Enhanced Blocked

10. Persis has been clean for 9 months and comes in to see her case manager about how she is really tempted to use again. Persis asks if there is something more she can do. The worker says, “Oh, come on. It’s been 9 months. Get down to busi- ness and focus on the good things in your life. It’s all up to you whether you use or not.” Can Persis continue to explore her temptation to go back on drugs with this worker?

Enhanced Blocked

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Chapter 8 Listening and Responding 169

Listening and Responding

Introduction

Listening well to others is therapeutic, a healing activity. For that reason, doing so effectively is very important. Although case managers do not practice therapy as we think of it in a counseling setting, they do have many opportunities to listen to oth- ers in a way that is therapeutic. At intake and during the course of the relationship as problems and issues arise, the case manager can offer listening as a first and important step in the resolution of people’s problems.

Writing in the American Journal of Psychiatr y, Dr. Stanley W. Jackson (1992, p. 1624) talked about the importance of listening:

The effective healer in the realm of psychological healing tends to be someone who is interested in talking with and listening to the other person. And these inclinations are grounded in an interest in other people and a curiosity about them. Further such healers have a capacity for caring about and being concerned about others, particularly about those who are ill, troubled, or distressed.

Describing those who seek our help, Jackson wrote, “He seeks to be listened to, to be taken seriously, and to be understood, as crucial aspects of this process.” Finally, he talked about the process itself:

The attentive listening of a concerned and interested healer can, and often does, have a compelling effect on the sufferer. The sufferer often enough responds by telling more about himself, by revealing more. . . . The rela- tionship is deepened—more is said, more is heard, more is understood, more of a sense of being understood is experienced.

Listening to another person in a way that indicates our concern for that person is important in the healing process. Reflective listening is a method that allows you to demonstrate such concern and interest in other people.

C h a p t e R 8

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170 Section 3 effective Communication

Defining Reflective Listening

Reflective listening is a term used to describe therapeutic listening and responding—a way of listening that is most helpful to people. This method of listening to others has three purposes.

1. Reflective listening lets people know you have heard their concerns and feelings accurately.

2. Reflective listening creates an opportunity for you to correct any mis perceptions. 3. Reflective listening illustrates your acceptance of where the person is at that

moment.

When someone talks to you, there are two aspects to which you can listen and respond:

1. The content of what the person has said 2. The feelings that underlie what the person has said

Responding to feelings is empathic and is, therefore, the most useful kind of response.

When you accurately respond to the feelings the person is experiencing, that person feels heard. Someone is really listening. When clients feel that you truly hear them and that you hear the feelings they are expressing, even when they do not explicitly describe those feelings, they begin to develop trust and rapport with you, making it easier for them to fully talk with you about their problems and issues. As you saw in the discussion of roadblocks to good communication in Chapter 7, there are many responses that are barriers to trust and rapport. You want to provide a safe, accepting environment where people feel free to express themselves. For this reason, it is important to learn how to provide empathic responses that will further a construc- tive relationship with your clients.

Responding to Feelings

When you let another person know that you have heard the feelings that person is expressing at that moment, you are being empathic. Empathy is the ability to hear and experience accurately the underlying feelings and emotions that clients are express- ing when they speak. We have empathy when we are able to put ourselves emotion- ally in their situations and clearly sense what they must be feeling. People may tell you how they feel in actual words, but much of our understanding of other people’s emotions comes from their facial expressions, body language, tone of voice, mood, and choice of words. In listening to feelings, we are listening to all of that as well as the words clients speak. In this way, we gain an understanding of the underlying emotions and concerns.

It is important to really listen. Instead, many of us are tempted to think while other people are talking. We think about how wrong they are. We think about what they could do instead. We think about what advice we should give them and how to solve their problem. What we really should be doing is listening for the feeling and

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Chapter 8 Listening and Responding 171

determining the degree of that feeling. For instance, a person may be angry or furious or just annoyed. Another person may be a little wistful, sad, or openly depressed. Can you tell the difference when you listen? Of course you can, when you are really listen- ing for the feelings.

Responding to feelings involves the following three steps:

1. Listening carefully to the client 2. Identifying the most prominent feeling you are hearing 3. Constructing a single statement that includes that feeling

This single sentence that includes the other person’s feeling is called an empathic response. This is a specific way to practice empathy for clients, to acknowledge clients’ feelings and concerns. We use a single sentence because to add more often distracts the person or moves the conversation away from the central concern. A single sentence allows people to know that they have been heard and that they are welcome to continue on the same track; they are reassured.

Reflective listening does not include advice or solutions. A reflective listener does not tell the other person to feel another way or to look at the problem from another perspective. A reflective listener does not judge the message or the feel- ings. See Figure 8.1 for some examples of correct and incorrect responses in different situations.

To a person whose new car was damaged in an accident:

Correct: “You must have felt pretty terrible about the accident.” Incorrect: “Before you get upset, you should call your insurance dealer.”

To a person who just lost her childcare:

Correct: “I’m sure this has been really difficult!” Incorrect: “Well, we just need another day care to take your daughter.”

To a person distressed over not finding a job:

Correct: “It sounds like you’re feeling pretty defeated.” Incorrect: “I’m sorry you couldn’t find work. Maybe you’ll have better luck tomorrow.”

To a person whose daughter has been removed because of child abuse:

Correct: “This isn’t going to be easy without her.” Incorrect: “This is what happens when the county feels kids are abused.”

In each good example the worker is beginning where the client is in order to be able to move with the client to a solution. In this last exchange, the worker can more easily talk to the client about the steps he or she needs to take to get her children back if she has first acknowledged how difficult this is for the person. Acknowledge first the feel- ings so the person feels supported and heard and then move to what needs to be done.

FIguRe 8.1 Correct and incorrect responses when listening to feelings

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172 Section 3 effective Communication

In the following dialogue, based on the situation in which a client has wrecked a new car, notice the way the worker stays with the client throughout the exchange:

client (sighing as he sits down): I wrecked my car yesterday on my way to work.

worker: It sounds like you feel pretty bad about it.

client (sighing again): I do. I guess I should be happy no one was hurt, but I just got the car.

worker: It was brand-new and perfect.

client: I know. I picked it out and ordered it special. It had everything I wanted. I don’t know, in a way it was my fault. She ran the stop sign, but I wasn’t really paying attention.

worker: You’re sort of blaming yourself for this.

client: Oh, I did. I still do. The police said she was clearly in the wrong. But now I’m going through all this unnecessary stuff with insurance and using a loaner car and trying to get a new car.

worker: You must feel so disrupted.

client: Yeah, I do.

Listen now as the same client speaks to a worker who is not trained in reflective lis- tening. Notice how the worker pursues her own agenda and how the client begins to sound defensive and ultimately stops participating:

client (sighing as he sits down): I wrecked my car yesterday on my way to work.

worker: You wrecked your car? How did you do that?

client (sighing again): I guess I should be happy no one was hurt, but I just got the car.

worker: Well, what happened?

client: The other driver ran the stop sign, but I wasn’t really paying attention. In a way, it was my fault.

worker: Well, you can’t drive and think about 10 other things. When you are driving a car, you have to pay attention to what is going on around you. If you’re daydreaming, it doesn’t work. You can’t do that when you’re driving.

client (sounding defensive): Well, I wasn’t really daydreaming or anything. I just didn’t notice her. You can’t always see everything the other drivers intend to do before they do it.

worker: I guess you can’t, but sometimes I think there are just too many drivers out there anymore.

client (nods): But now I’m going through all this unnecessary stuff with insur- ance and using a loaner car and trying to get a new car.

worker: Well, that’s all part of it. When you wreck your car you’re tied up for months with all the bureaucratic paperwork. And they never give you what you need to buy another one just like it.

client: Uh-huh.

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Chapter 8 Listening and Responding 173

Let us look at another example of good listening. Notice how the worker in this next example identifies the strongest feeling present in what the client is saying and how the client almost always responds positively to that recognition:

client (tears welling up in her eyes): I never went through this before.

worker: It sounds like you are devastated.

client (nodding and crying more openly): My dad died, last week. He . . . he . . . well, he had been in dialysis, but he seemed so good Sunday night. Then Monday the nurse called me at work—oh, I guess around 10:00—and suggested I come in, but she didn’t say it was an emergency or anything.

worker: You must have felt you didn’t have to rush, that you had a little bit of time.

client: Well, no, I went in as soon as I finished up what I was doing, and here he was already in intensive care. His breathing was so labored, so hard for him . . . (cries).

worker: That must have been a shock!

client: It was! I couldn’t believe it. That was my dad lying there. He just fixed my electrical outlet 2 weeks ago. We went out to eat for his birthday. I just couldn’t believe he would go now.

worker: It was all so sudden.

client: Oh yes, and then they are talking to my mom and I about how to make him comfortable. He knew me and all, but he couldn’t talk. And you know how they say people need permission to die? Well, I told him it was okay to go (cries). I told him he gave his life a good shot and he could go (whisper- ing). And he did (cries).

worker: That must have been so painful for you.

Now observe what happens in this situation when the worker’s listening skills are inadequate. Notice in this example how the worker brings the conversation around to a more cheerful topic. In this case, the worker may very well be protecting himself from feeling the enormous pain of the client:

client (tears welling up in her eyes): I never went through this before.

worker: Like what?

client (crying more openly): My dad died last week. He . . . he . . . well, he had been in dialysis, but he seemed so good Sunday night. Then Monday the nurse called me at work—oh, I guess around 10:00—and suggested I come in, but she didn’t say it was an emergency or anything.

worker: So you went right in!

client: Well, no, I went in as soon as I finished up what I was doing. I didn’t think she meant I had to hurry, and here he was already in intensive care. His breathing was so labored, so hard for him . . . (cries).

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174 Section 3 effective Communication

worker: Did he have a living will? That would have helped you to know how to handle this.

client: I don’t think he did. I don’t know. Mom and I made the decisions. We knew he couldn’t go on much longer, and we didn’t want him to suffer. I couldn’t believe it. That was my dad lying there. He just fixed my electri- cal outlet 2 weeks ago. We went out to eat for his birthday. I just couldn’t believe he would go now.

worker: We never really know when death will strike, do we? We just have to look on the bright side, at all the good times we had with people while they were here. We know our parents won’t live forever.

client: It isn’t that I thought he would live forever. It was just so sudden or something. We didn’t have much warning really. I guess in that respect I can say he didn’t suffer, you know, like in a long illness for years and years.

worker: See. There’s something to be thankful for. There is a silver lining in everything.

client: Sure.

Did you notice that the client stopped crying? She took the cue from the worker that crying and continuing with the painful story about her father’s death was being dis- couraged. It must have been clear to you as well that a significant part of the story was left out. The first worker received more information about what really happened by saying less. The second worker said more, but cut off part of the story and, therefore, did not receive as much information.

Good listeners stay with people until their emotions are drained off. If a client cries, we know we are helping that person to face and come to terms with intense emotion. People who are supported through this process by skilled listeners heal better than people who have been forced to shut down their feelings in front of the worker and deal with them alone.

Responding to Content

When you respond to the content of what clients say, you are usually doing it to check the accuracy of the information you believe you heard. Listening to content gives you clarity and helps you understand the facts. If the event the person is talking about was traumatic, listening to content helps that person to begin to hear and integrate this experience. We are helping that person to come to terms with what happened and heal. Generally, we listen to content less often than we listen to feelings. Figure 8.2 provides some examples of correct and incorrect responses in terms of listening to content.

Responding to content is a good way to help people who have just been through a traumatic event. As noted, when you repeat the facts of the traumatic event back to the person, the individual can begin to integrate her particular experiences into the whole of her experiences, and her healing is facilitated. In fact, the sooner people

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Chapter 8 Listening and Responding 175

To a person who is describing losing everything in a fire:

Correct: “So the fire started in the back of your neighbor’s house and spread to your back porch?” Incorrect: “Sounds like a bad fire!”

To a person who is telling the worker about hearing voices:

Correct: “In other words, these voices have kept you awake at night telling you that there are people watching the house.” Incorrect: “Your hearing voices means you need to see Dr. Preston.”

To an older person whose health has meant she must move into an assisted living facility when she would rather be home:

Correct: “Sounds like you had a wonderful home over on Locust Street and good neighbors.” Incorrect: “Moving here does mean giving up your home and your neighbors.”

To a child in a shelter who is telling about how he saw his dad arrested for assaulting his mother.

Correct: “So the police came to the house and took your dad outside and you and your mother were told to stay in the house.” Incorrect: “Police arrest men that beat women.”

In each good example the worker is beginning where the client is in order to be able to help the person tell more and come to terms with what happened. In each correct exchange, the worker elicits more information than would be given when using the incorrect responses and, therefore, will have a better understanding of what happened and how the person feels about it.

FIguRe 8.2 Correct and incorrect responses in listening to content

begin this process after a traumatic event, the more readily they may be able to heal in the future. Here is an example of a worker who listens to the content of a client’s discussion of a traumatic event:

client (looks pale and shaken, and is silent)

worker (responding first to feeling): It seems like you’ve been through something pretty terrifying.

client (nods): I . . . Can I tell you? It was . . . in the parking garage at the hotel. Not late or anything. I heard this person get off the elevator as I . . . (is silent).

worker: You had gone to the parking garage to get your car.

client: Yes, and as I was walking toward the car, and it was at some distance, I thought I heard the elevator, and then someone started walking along behind me.

worker: The person was walking behind you, but at that point you thought the person was just going to a car.

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176 Section 3 effective Communication

client: Right. And just as I was ready to get in my car, . . . I mean, I almost made it, and he grabbed my coat and just pulled, just pulled as hard . . . just pulled me backward.

worker: So, in other words, you were grabbed and pulled down from behind.

Notice that the worker rephrases the facts the client gives so that the client hears them again. Through this listening process, it is not uncommon to find that unpleas- ant memories, which the client has blocked, begin to surface in the supportive atmo- sphere created by the worker. At this point, some people might say the client is lying or making up things because the story has changed somewhat. More often, however, the client is beginning to remember more of what actually happened because the worker is encouraging and has created a safe environment.

Positive Reasons for Reflective Listening

Some specific therapeutic reasons have been given for employing reflective listening. These are described in the following two sections.

Self-Acceptance

Arnold Beisser (1970), writing about Fritz Perls’ ideas, talks about Perls’ paradoxical theory of change. The theory asserts that people change only when they are able to accept themselves exactly where they are right now.

Judgments about where clients should be only engages them in defending how they came to the place they are now. This wastes clients’ energy and the valuable time you have to work on healing. When you accept where the person is at the moment, the individual can accept herself and move forward. The most healing, and therefore the most therapeutic, practice is reflective listening. By saying “You must be angry,” you accept the fact that the client is angry. If you say “You should try to curb your anger and think more positively,” the client then has to explain why she has not done so or cannot do so. In this situation, some people say nothing and decide you do not really understand. By accepting, without judging, where the person is now, he can then move on toward something better. People cannot move in a positive direction until they have accepted where they are now.

Drain Off Feeling

In the human service profession, you will meet people in all sorts of life crises and difficulties. Some of the circumstances are very traumatic, and considerable reflective listening will be required on your part if the people are to begin the healing process. A woman who has been raped will start coming to terms with it sooner and heal more readily if she encounters a good reflective listener soon afterward. An older person can prepare for the end of life and feel comfortable about his past life if he can talk about it with a good reflective listener.

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Chapter 8 Listening and Responding 177

Human service workers have been criticized for not listening long enough. Some take only a few stabs at it, and then move into problem solving: Where will this person stay tonight? Who should I call? What facts do I need to open this case? The importance of your role in trauma, in healing, and in helping clients to grow cannot be overestimated. You play that role in large part by practicing good reflective listening.

Points to Remember

Listen Reflectively Long Enough

Do not cut short this important piece of the client’s healing process because you feel pressed for time. Be sure you go over the situation thoroughly once and, if you can, review it several times. In cases of violence, reviewing the content several times, along with listening to feelings, helps the victim begin to hear the story and come to terms with it. Reflective listening, in this case as in others, promotes healing.

Introducing Solutions

Do not rush to the solution phase of the interview unless the person seems extremely anxious about what will happen. Even if you have ideas, wait until the emotion has been drained off.

You cannot confront the issues you feel are important if you have not done your reflective listening first. If you do, the client may go along with you, but not as well or with as much involvement as she would if she felt heard and understood. For instance, if you immediately explore your concerns about where the client will stay tonight instead of acknowledging the loss of her home in a fire just hours ago, she will not be as ready to work with you on solutions. Her mind is on her many losses, and her emotions may be ranging from guilt to anger. Listen first. Likewise, if you try to help a young couple with the details of their baby’s funeral without listening to their story about the baby and the baby’s death, you will be taking care of the details that matter most to you, but the clients are likely to experience you as unfeeling and impersonal. By starting where they are, you can help them to move toward the matters that must be addressed. Most important, you help them to integrate this experience into the whole of their life experiences, making it easier for them to ultimately accept the reality.

If the client would obviously feel comforted to know there are solutions or resources, tell him about these first, but then demonstrate reflective listening at another point in the interview. If the interview is pressed for time, after you give the information that is needed, give at least one reflective listening response. “I know los- ing your home has been devastating for you” or “This evening must have been heart breaking.” The person will leave feeling as if he is understood.

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178 Section 3 effective Communication

Reflective Listening Does Not Mean You Agree

Just because you say to a client “You must feel very angry” does not mean you think the client should feel angry or should not feel angry. You are simply acknowl- edging where the person is right now. You have accepted that. This makes it easier for him to accept that. Now he can more easily move from being angry to some- thing better.

You Could Be Wrong

Suppose you say to a client, “It must have made you sad to see your parents go through that.” The client responds, “Well, not really. I think I felt more anger than sadness.” This is a good exchange. Here you get important, corrected information that allows you to follow the client’s concerns more accurately. Reflective listening allows us to clarify and correct things so that we are following where the client is at the moment.

Mind Your Body Language

To facilitate the interview, lean toward the client, look the person in the eye, nod, and look interested and enthused. While the client is talking, do not fiddle with things on your desk, lower your head to write, stare out the window, or glance at your watch. Give body language signals that indicate you are being attentive to what the person is saying. Do not stand over people talking down at them. If the client is in a wheelchair or is a small child, get down to a level where you can make eye contact. Pull up a chair so that you can look at the person directly.

Summary

Good listening is one of the most supportive and healing techniques you will practice in your work with other people. The opportunities to provide solace through good listening skills are numerous and occur in many diverse settings where people come for help. What you give to people in uncertain circumstances and difficult times is the gift of truly being heard and understood. You bring with you the warmth and interest in people that makes them feel valued. Their story is an important story to you. Their anxiety or sad feelings are noted and responded to. Whether or not you are able to effect a positive resolution to people’s problems, your listening skills will always provide the support people need to take up the tasks of their lives and go on.

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Chapter 8 Listening and Responding 179

Video Examples

To view the videos that accompany this book, go to CengageBrain.com.

• You can see Keyanna responding to the underlying feelings Michelle has about her situation by watching “The First Interview” online. Two other vignettes demonstrate how this is done: “Developing a Service Plan” and “Helping Tom Solve a Personal Problem.”

Exercises

These exercises can also be filled out online at CengageBrain.com.

Exercises I: How Many Feelings Can You Name?

Instructions: In a group of no more than four people, see how many feelings you can name in 10 minutes. Remember that there are many different degrees of the same feeling. After you do the exercise check your list against the list in the appendix.

Exercises II: Finding the Right Feeling

Instructions: When responding to feelings, it is important to know the intensity of the feeling. It is very important to reflect to clients an accurate reading of what they must be feeling. All feelings have varying degrees of intensity. For each word listed here, list other words that mean the same thing but indicate varying degrees of the feeling identified by the original word. The first one is done for you as an example. Check the list of feelings in the appendix to see if there are other words you missed.

HAPPY: overjoyed, exhilarated, glad, delighted, cheerful, ecstatic, merry, radiant, content, elated, euphoric, ebullient, chipper, bouncy, bright, joyful, pleased

SAD:

CONFUSED:

TENSE:

LONELY:

STUPID:

ANGRY:

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180 Section 3 effective Communication

exercises III: Reflective Listening

Reflective Listening I

Instructions: People communicate words and ideas, and sometimes it seems appropriate to respond to the content of what someone has just said. Behind the words, however, lie the feelings. Often it is most helpful to respond to the feelings.

Following are statements made by people with problems. For each statement, first identify the feeling; write down the word you think best describes how the person might be feeling. Next, write a brief empathic response—a short sentence that includes the feeling. Refer to the sample openers provided in Chapter 7 under the heading “Useful Responses.”

1. “When I was in court, the defense attorney really pounded me. You know, like he thought I was lying or didn’t believe me or thought I was exaggerating.”

FEELING:

EMPATHIC RESPONSE:

2. “Those dirty, lousy creeps! Everything was fine in my life, and they really, really ruined everything! I don’t care if I go on or not. Why live if someone can just take everything away from you in one night?”

FEELING:

EMPATHIC RESPONSE:

3. “I know you said this is temporary housing and all, but I never had a place like this place. I can’t stand to think I have to move again sometime, and God knows where I’ll go.”

FEELING:

EMPATHIC RESPONSE:

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Chapter 8 Listening and Responding 181

4. “This whole setup is the pits. He gets to stay in the house after beating me half to death, and I have to go to this cramped little room. Does that make sense?”

FEELING:

EMPATHIC RESPONSE:

Instructions Part II: Now go back and respond to the content in each of these vignettes.

Reflective Listening II

Instructions: People communicate words and ideas, and sometimes it seems appropriate to respond to the content of what someone has just said. Behind the words, however, lie the feelings. Often it is most helpful to respond to the feelings.

Following are statements made by people with problems. For each statement, first identify the feeling; write down the word you think best describes how the person might be feeling. Next, write a brief empathic response—a short sentence that includes the feeling. Refer to the sample openers provided in Chapter 7 under the heading “Useful Responses.”

1. “Sometimes it kind of makes me sick to think of all the stuff I did when I was drinking. I’d like to go and take it all back, but how do you ever do that?”

FEELING:

EMPATHIC RESPONSE:

2. “I just can’t go out in the car. All I hear is the screech of tires and the awful thud and scrape of metal. I thought I was dying. I can see it all before me as if it was yesterday.”

FEELING:

EMPATHIC RESPONSE:

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182 Section 3 effective Communication

3. “We have a neighborhood problem here! Yes we do! A real big idiot lives in that house. A real nut! He trimmed my own yard with a string trimmer and threw stones all over my car. Ruined the paint!”

FEELING:

EMPATHIC RESPONSE:

4. “I never meant to get pregnant. I know everyone says that, but I didn’t! I can’t think straight. What about my job and school and all my plans? I feel sick. I feel all the time like I’m going to faint.”

FEELING:

EMPATHIC RESPONSE:

Instructions Part II: Now go back and respond to the content in each of these vignettes.

Reflective Listening III

Instructions: People communicate words and ideas, and sometimes it seems appropriate to respond to the content of what someone has just said. Behind the words, however, lie the feelings. Often it is most helpful to respond to the feelings.

Following are statements made by people with problems. For each statement, first identify the feeling; write down the word you think best describes how the person might be feeling. Next, write a brief empathic response—a short sentence that includes the feeling. Refer to the sample openers provided in Chapter 7 under the heading “Useful Responses.”

1. “I can tell you now, I just can’t go back there. I just feel as if my husband will kill me one of these times.”

FEELING:

EMPATHIC RESPONSE:

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Chapter 8 Listening and Responding 183

2. “I can’t stand those people! They made fun of that retarded kid night and day. I hope they get theirs!”

FEELING:

EMPATHIC RESPONSE:

3. “I’ve been clean for 8 months! If you had told me this would happen a year ago, I’d have laughed in your face.”

FEELING:

EMPATHIC RESPONSE:

4. “When I was a little kid, my mom and dad got along okay, but now they fight all the time, and my mother says my dad is on drugs and has a girlfriend. Home is like hell.”

FEELING:

EMPATHIC RESPONSE:

Instructions Part II: Now go back and respond to the content in each of these vignettes.

Reflective Listening IV

Instructions: People communicate words and ideas, and sometimes it seems ap- propriate to respond to the content of what someone has just said. Behind the words, however, lie the feelings. Often it is most helpful to respond to the feelings.

Following are statements made by people with problems. For each statement, first identify the feeling; write down the word you think best describes how the person might be feeling. Next, write a brief empathic response—a short sentence that includes the feeling. Refer to the sample openers provided in Chapter 7 under the heading “Useful Responses.”

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184 Section 3 effective Communication

1. “When I took that test, it was really hard. And I guess I was nervous. I mean, I couldn’t think of any of the answers.”

FEELING:

EMPATHIC RESPONSE:

2. “Those guys are lousy! They’re always snickering and making fun of other peo- ple, especially people who have a disability. They make me sick!”

FEELING:

EMPATHIC RESPONSE:

3. “I know Jim said we could be buddies at swim practice, but I’m probably not as good a swimmer as he is. I feel sort of silly trying to swim with him. Maybe he would like to have a better buddy.”

FEELING:

EMPATHIC RESPONSE:

4. “This whole setup sucks. This other guy gets the tutor, and the teacher tells me to go home and see if my mother can tutor me. She never had this math. Math isn’t even her thing. Does that make sense?”

FEELING:

EMPATHIC RESPONSE:

Instructions Part II: Now go back and respond to the content in each of these vignettes.

Reflective Listening V

Instructions: People communicate words and ideas, and sometimes it seems ap- propriate to respond to the content of what someone has just said. Behind the words, however, lie the feelings. Often it is most helpful to respond to the feelings.

Following are statements made by people with problems. For each statement, first identify the feeling; write down the word you think best describes how the person might be feeling. Next, write a brief empathic response—a short sentence that

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Chapter 8 Listening and Responding 185

includes the feeling. Refer to the sample openers provided in Chapter 7 under the heading “Useful Responses.”

1. “Well, every time I go off my meds, I get kind of crazy. My minister is really put- ting the pressure on me to quit and let God take over my illness.”

FEELING:

EMPATHIC RESPONSE:

2. “The people at the halfway house are so nice to me, compared to the way things were with my family.”

FEELING:

EMPATHIC RESPONSE:

3. “You have some nerve, having the therapist see my son every week for 6 months, and then you refuse to tell me more than ‘he’s doing better.’ How do I know he’s doing better?”

FEELING:

EMPATHIC RESPONSE:

4. “I’ve been on the streets since 1972, and I never slept inside a night until now. I don’t know, I just can’t seem to stay out like I used to without getting this cough.”

FEELING:

EMPATHIC RESPONSE:

Instructions Part II: Now go back and respond to the content in each of these vignettes.

Reflective Listening VI

Instructions: People communicate words and ideas, and sometimes it seems ap- propriate to respond to the content of what someone has just said. Behind the words, however, lie the feelings. Often it is most helpful to respond to the feelings.

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186 Section 3 effective Communication

Following are statements made by people with problems. For each statement, first identify the feeling; write down the word you think best describes how the person might be feeling. Next, write a brief empathic response—a short sentence that includes the feeling. Refer to the sample openers provided in Chapter 7 under the heading “Useful Responses.”

1. “I can’t believe I was that intoxicated! I just don’t believe it. Their gizmo must have been broken or something. I just didn’t drink that much and I wouldn’t be driving if I had!”

FEELING:

EMPATHIC RESPONSE:

2. “You don’t expect us to take Alfred into our home, do you? He is very mentally ill—tore up the house several times. I really—well, I know he’s my son, but I just can’t deal with the way he’s been in the past.”

FEELING:

EMPATHIC RESPONSE:

3. “I can tell you what scares me most. It’s being by myself at the house one night and having him come back. I don’t know if I can go on living there.”

FEELING:

EMPATHIC RESPONSE:

4. “I just can’t go to class. Not after making a fool of myself the last time. I got every answer wrong when the teacher called on me, and people were making fun. . . . It was terrible!”

FEELING:

EMPATHIC RESPONSE:

Instructions Part VI: Now go back and respond to the content in each of these vignettes.

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Chapter 9 Asking Questions 187

Asking Questions

Introduction

When listening to another person’s difficulties, we might find ourselves asking a lot of questions. We usually mean well. In part, we do this to find out more so a solution can be quickly devised. We also do this as a way of filling in the gaps when our reflective listening skills are not strong. It may be easier for the listener to say “Did you have any money?” or “Where did the man say he lived?” than to simply say, “Tell me about what happened.”

Sometimes when we listen, we feel nervous about what the other person expects from us. After all, if we are the worker, should we not have all the answers? If we do not have an answer just yet, we can stall for time by asking a lot of questions until we do.

Often, however, the client hears these questions as prying. You may ask ques- tions at a rate the client is not ready to answer. For instance, you may be asking ques- tions further ahead in the story, throwing the client off. Clients may feel pushed to reveal more than they intended or be distracted from the line of reasoning they were following. They may become defensive and their communication guarded if the ques- tions seem to pry or to imply there is only one way to have handled things.

When Questions Are Important

Obviously, at times questions need to be asked. The three times it is important to ask questions are as follows:

1. When you are opening a case or chart for a person and need identifying informa- tion (closed questions)

2. When you are compiling information for assessment and referral purposes and need facts to do that properly (closed questions)

3. When you are encouraging the person to talk about his or her situation freely to bet- ter understand which aspects of it are important to the individual (open questions)

C h A p t e r 9

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188 Section 3 effective Communication

Closed Questions

A closed question is one that requires a single answer. For example:

worker: Where do you live?

client: 346 Pine Street.

worker: How long have you lived there?

client: Oh, about 6 years.

worker: Have you ever been seen here before?

client: Yes, in 2013.

worker: And who did you see then?

client: Dr. Langley in outpatient.

worker: Did she prescribe any medication?

client: Yes, she gave me a prescription for Prozac.

worker: Do you still take that?

client: No, I stopped a few months ago.

Closed questions are most often used when opening a case or when compiling infor- mation for an assessment. In both of these instances, however, clients will need to talk about what has brought them into the service, and you will not rely exclusively on closed questions. Nevertheless, some closed questions are appropriate here to gather the basic information. The person can respond with a simple answer because the questions do not ask for expressions of feelings, descriptions of circumstances, or explanations of problems.

Let’s look at another example. Notice that the questions require a single, simple answer.

worker: You are coming here directly from rehab?

client: Yes

worker: And you were at Middleton?

client: Yes

worker: Was it drugs, alcohol?

client: I had a drinking problem

worker: How long were you at Middleton?

client: About a month

worker: Do you have a job to go back to?

client: Yes, over at the Farmington Warehouse

worker: What is your job there?

client: I am in charge of one of the shipping lines

Remember that asking one closed question after another about a person’s situa- tion or problem can sound as if the case manager is prying or frantically trying to find a solution, rather than trying to understand what really concerns the client.

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Chapter 9 Asking Questions 189

Open Questions

Open questions serve the purpose of giving clients more opportunity to talk about what is important to them. By asking open questions, you receive more information about a client’s situation. In answering open questions, the client can talk about feel- ings, underlying causes, supporting circumstances, and personal plans.

Open questions have been shown to put clients at ease. Workers using these questions are not perceived as prying but as expressing real interest in other people or a genuine desire to understand their situation. You can use open questions to obtain examples or elaboration of the problem and to clarify certain aspects of the other per- son’s story.

An open question allows the other person to talk freely about his or her issue. As you listen you find out what is most important to this person about her situation. You are better able to see the other person’s point of view. You can better hear her emotions. Open questions give us much more valuable information than closed ques- tions can. For this reason, learning to ask good open questions will enhance your understanding and your ability to establish good rapport.

Often an open question begins with “can” or “could,” but there are other ways to start such questions. For example, you might say, “Tell me a little bit more about your divorce.” Typically open questions look something like this when listening to the individual talk about his issues:

worker: Can you tell me about the night your father left?

client: Well, my mother had been arguing with him for some time. I could tell he was getting angry. I don’t think I really blame her for his leaving. He had done many things to her that she had every right to be angry about. But I guess for him it was the last straw. Anyway, we were having dinner and she began on the same topic of the house. He just put down his fork and got up from the table and walked out of the house.

worker: Can you describe your relationship with him after that?

client: Well, he did come back to the house for his things from time to time. He got an apartment nearby, and I used to stop there on my way home from school. We never stopped seeing each other, and we never talked about my mother. I can’t ever remember him asking me how she was or, for that mat- ter, saying anything mean about her.

Would the worker have gained as much information by conducting the same conver- sation using closed questions? This example demonstrates that the client would have been much less forthcoming:

worker: When did your father leave?

client: I think, August of 2006.

worker: Did your parents argue much before he left?

client: Sure, yeah, a lot of the time.

worker: Why did he go?

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190 Section 3 effective Communication

client: Well, they disagreed over money and about the house.

worker: After he left, where did he go?

client: He got an apartment near us.

worker: Did you ever see him after that?

client: Yes, pretty much.

Would the client have felt investigated with these short closed questions fired at him, one after the other? Did the worker really understand how the client felt about the divorce and the contact with his father?

In the second example, in which the worker used closed questions, there was room for the worker to assume things that might not be true. For instance, the worker might have assumed that the client blamed his father for leaving. In the first example, in which the worker used open questions, the client’s elaboration on the situation demonstrated that this clearly was not the case.

Questions That Make the Other Person Feel Uncomfortable

The Trouble with “Why” Questions

There are three ways that “why questions” can seem offensive or make another per- son feel uncomfortable. If you ask someone why someone did something or did not do something, you imply that you believe the person should have handled things differently.

• “Why didn’t you call the police?” • “Why did you spend all that money?” • “Why did you let your children stay out that late?”

Sometimes why questions seem to seek a level of understanding or insight the client may not have. The client has to search for an answer or is pushed to come up with an explanation.

• Why do you think you chose to go to that particular bar? • Why was it that you and he had that fight on that evening? • Why is it that each of these incidents happened after she was out with her

friends?

At other times why questions can sound like prying, asking for information the client had not intended to discuss.

• Why did you have a fourth child so soon after the third one? • Why didn’t you ask yourself why you chose to do it that way? • Why are you always avoiding going up to the college to at least get some

information?

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Chapter 9 Asking Questions 191

Asking Multiple Questions

If you fire off a string of questions, the person can feel interrogated. You may sound impatient, and you can confuse the client.

“Did you see the other person? What did he look like? Did you get a li- cense plate number or some identifying information? How close were you? Did anyone else have information that would identify him? Did the police have any suggestions?”

Too many closed questions can sound as if you are desperately trying to solve the problem for the client. In the example above the worker is getting bits and pieces of information, but probably would have done better to simply have asked, “Tell me about what happened that night?” Then one or two closed questions might have filled in the gaps without pressuring the other person.

Questions That Change the Subject

If the person is talking about how she learned of her mother’s death, do not start asking questions about her mother’s prearranged funeral. Let the client continue to talk about her mother’s death until it seems that she wants to turn to the prearranged funeral. Never ask about something out of curiosity. Do not ask, for example, about the prearranged funeral because you are thinking of getting one for your mother and want to know more about it. Ask questions that stay on the topic the client has selected. If you do ask questions on another topic, make sure the topic is relevant and the questions will actually clarify the person’s situation for you.

Here are some examples of questions that change the subject:

• “I heard about the kids before, but where do you work?” • “So, she died on Saturday, and now you are seeing a lawyer about the will?” • “That’s real neat about how your car looked before the accident. Do you have

adequate car insurance?” • “So, your mother died on Saturday, and you’re living in a house by yourself?”

Sometimes questions such as these can disrupt the entire discussion as for instance when the client said, “I got this brand new Mustang with V-6 performance and a six speed transmission. It was ruby red, a really great car.” If the worker responds with, “That’s real neat about how your car looked before the accident. Do you have adequate car insurance?” the person is likely to respond with something like, “yeah” or “sure.” Talking about the car’s great features before the accident would end there, possibly leaving the client somewhat annoyed. For the worker, changing the subject cuts off any real understanding of what the person feels he lost.

Implying There Is Only One Answer to Your Question

You can ask questions in a way that implies there is only one acceptable answer.

• “Didn’t you go to the police?” • “Did you tell the other person what you heard?” • “Did you see to it that he knew what you were thinking?”

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192 Section 3 effective Communication

Inflicting Your Values on the Client

You can also ask questions based on your own value system. The client, however, may have other values. For example, you may value truthfulness at all costs, whereas your client may come from a group that values group harmony and not hurting another per- son’s feelings. Questions that imply that your value system is better are not useful.

• “Did you tell her how you felt before you just walked out?” • “Did you tell her the complete truth?” • “Don’t you value truth above everything else in this situation?”

Do Not Ask Questions That Make Assumptions

You can word questions in such a way that they make it clear you are assuming you already know the answers.

• “You called the police, right?” • “You wanted to go to the store, didn’t you?” • “He was being a fool, wasn’t he?”

A Formula for Asking Open Questions

Figure 9.1 contains a formula for asking open questions. In the figure, the open ques- tion is broken into parts. You can interchange the parts, by choosing one part from each column, to construct good open questions that encourage the other person to feel safe in talking and expressing feelings and opinions. Use this formula in the exer- cises at the end of this chapter to construct effective open questions that invite others to be open and talk freely with you.

Some Tips for Asking Open Questions

Learning to ask open questions takes practice. It is easy to ask a closed question, such as “Where do you live?” or “How old are you?” When intending to ask an open ques- tion, we often start out well and then unwittingly close the question. Some examples of what can happen are presented next.

A Question That Is Not Really Open. “Tell me a little bit about how you got here?” “How you got here” is a closed question and the client can answer, “I came over in the car.”

To Open That Question Try This. “Tell me about getting here.” The client is more inclined to say more, such as “Well, I came over in the car, but it was scary. I kept looking in my rearview mirror to see if he was following me.”

Words That Snap Questions Closed Are How, Why, What, When, Where. You may not be able to avoid using these words in some of your open questions, and using these words in questions is perfectly all right. To leave them out might mean your

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Chapter 9 Asking Questions 193

question doesn’t make sense. However, when our purpose is to draw people out and make them feel comfortable about talking to us in depth, we want our questions to be as open as possible. When you are about to use one of these words—how, why, what, when, or where—see if you can leave it out for a more open question.

instead of: “Tell me a bit about how you found out about your husband’s cheating.”

ask: “Tell me about finding out about your husband.”

instead of: “Can you describe why you left him?”

ask: “Can you describe leaving him?”

instead of: “Could you tell me a little bit about what the doctor said?”

ask: “Could you tell me a little bit about visiting the doctor?”

instead of: “Can you summarize for me when you left?”

ask: “Can you tell me about leaving?”

instead of: “Tell me a bit more about where you were that night.”

ask: “Tell me a bit more about that night.”

If we look at one of those pairs of questions carefully, we can see that the two questions are asking for somewhat different information. For example, in respond- ing to the question “Tell me a bit more about where you were that night,” the

FIgURe 9.1 Formula for asking open questions

© C

en ga

ge L

ea rn

in g®

Openers Directives Add-ons/Softeners Object of the Question

Can youa share a little bit more about your husband

describe a little bit about your childhood

explain a little more about your medication

summarize something about what the move was like

outline the problems with the move

spell out the larger picture regarding the move

Could youa talk a little more about what your dad said

give me a bit more about your illness

tell me something more about your job

help me understand

something about your relationship with your kids

clarify a bit the situation

aIt is fine to leave the “can you” or “could you” out of the questions. In this case, you would make a request such as “Share a little bit more about the fire.”

Digital Download Download from CengageBrain.com

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194 Section 3 effective Communication

person might tell you where she was and perhaps in addition give you some valu- able information beyond that: “I was down by the railroad tracks. I thought I could hop a freight or something like that. I just wanted to get away.” When you say “Tell me about that night,” you are asking him for much more, and he may be inclined to tell you many more details: “I was feeling terrified. I didn’t know who these people were or why they had singled me out. I didn’t know what to do or where to go so I went down by the railroad tracks. I think I thought I could jump a freight or some- thing like that. I just wanted to get away. I saw it starting to get light. No one came, and finally I got up and snuck home.” In this last example we know a lot more about the night in question, and we have some idea about the client’s perceptions and feelings as well.

Open Questions Complement Reflective Listening. Open questions and reflective listening complement each other and go a long way toward putting the other person at ease. Here is an example of how you would combine both open ques- tions and reflective listening in a good interview.

worker: Tell me what brought you in today.

client: My pastor, Reverend Perkins, sent me down after I had a bad time in church. He thought maybe I was depressed.

worker: Can you tell me a little bit about what happened in church?

client: Well, see they have this call to commitment every Sunday. It is for people who want to join the church so, you know, new people go up. But I always feel that my commitment isn’t good enough so I go up every Sun- day and he didn’t think I needed to do that. He asked me after church to talk to him about it and that is when I just broke down.

worker: It sounds like you haven’t felt really good about each of those commit- ments you made.

client: No. Right. I just think well I sinned all week and I need to recommit, but it is never good enough.

worker: Tell me a little bit about breaking down.

client: Oh . . . (begins to weep) I just tried to tell him how important it is to be right with the Lord. I don’t want anything to happen to me and I tried to tell him that. I feel as if God is mad at me or something and I need to do this every week to be sure . . . (her voice trails off ).

worker: So you feel that if you don’t make a recommitment each week some- thing bad will happen to you.

client: I do feel that way, but see the way Reverend Perkins says, the call for commitment is for people who want to join the church and . . . he didn’t say that but I think he thinks I am making a fool of myself. You know, every- body sees me do that every Sunday.

worker: You must feel really caught between wanting to please God and not wanting to go against your pastor.

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Chapter 9 Asking Questions 195

client: Yeah. I don’t know what to do.

worker: Can you tell me a little bit more about your church?

In this exchange the worker stays right with the client as the client explains why she came in for help. The worker combines open questions with reflective listening to draw out the feelings and circumstances of this person’s problem. We begin to know a lot about this person: her fears, her beliefs, what is important to her.

Summary

Asking questions helps us to understand our clients and the issues that are bothering them. Asking too many questions, however, can give the impression that we are desper- ately seeking some sort of solution or prying. The problems people bring to us are theirs. They need someone to listen to their concerns and sort out the best way to approach a solution. We help people do that by listening and asking open questions that encourage them to tell us more about what has brought them to us for help. It helps them to be able to talk about their problems and to hear their concerns reflected back to them.

Combine open questions with reflective listening to feelings and to content in order to create a safe environment for clients to talk to you and begin to work on prob- lem solving. Ask closed questions sparingly, but remember that an occasional closed question is perfectly acceptable; For the most part, confine them to times such as when you are opening a case or you need information to make a proper referral.

Video Examples

To view the videos that accompany this book, go to CengageBrain.com.

• You can see Keyanna use open questions to learn more about Michelle’s situ- ation by watching “The First Interview.” Danica uses open questions to work with Alison on her service plan in “Developing a Service Plan” and “Helping Tom Solve a Personal Problem.”

Exercises

These exercises can also be filled out online at CengageBrain.com.

Exercises I: What Is Wrong with These Questions?

Instructions: Read the questions that follow and decide what makes them bad questions. In writing your criticism, look for questions that assume there is only one answer, inflict values on the individual, make the person defensive, make assump- tions, cut off discussion, or change the subject.

1. A woman is telling a worker why she has come to the shelter tonight. Right in the middle of her gripping tale about what was going on at home only a few hours before, the worker says, “How long has this been going on?”

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196 Section 3 effective Communication

2. A worker has listened to a young mother talk about how she dropped out of school and got pregnant and has no skills. Finally the worker interrupts to ask, “Did you have to get pregnant? Didn’t you know about birth control?”

3. A man calls and says he is depressed. He has felt depressed for some time and is now thinking of suicide. The worker asks, “Where is your wife? Are you divorced?”

4. A man is telling you about the night he witnessed a murder. The victim was his brother-in-law, and although he was never very close to him, he feels that maybe he could have stopped his death in some way. The worker asks, “Why don’t you just go and ask the police?”

5. A woman has come into temporary shelter with a lot of debts. She has been out looking for work today and is discouraged about not finding anything yet. She sits down tiredly in the worker’s office and talks about what her day was like. The worker asks, “Did you have to get so many debts?”

6. A man wants to know if his wife is all right after she has been raped. He is sitting with a worker in the waiting room while his wife is being seen in the emergency room. The worker answers his question with one of her own: “How much does your wife mean to you?”

7. A patient in a partial hospitalization program for the chronically mentally ill tells the worker that when the group went to the mall, one of the patients took a pair of socks without paying for them. The worker asks, “You told someone right away, didn’t you?”

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Chapter 9 Asking Questions 197

8. A woman is telling about the time her coworkers waste when the supervisors are out at meetings all day. The worker responds, “Why don’t you say something?”

9. A woman tells a worker about a long and difficult marriage she has endured. She mentions abuse, both verbal and physical, and talks about her own failing health in recent months. The worker asks, “Why can’t you just bring yourself to divorce him?”

10. A man is trying to sort out whether or not to leave his employer. He feels that the small company is poorly run and that he could do a better job if he went out on his own. On the other hand, he likes his employer, and he feels sorry for him and the mess he’s made of his business. He knows that if he leaves, things will really fall apart. The worker asks, “Don’t you value loyalty?”

exercises II: Which Question Is Better?

Instructions: Read the following questions and decide which of them are better than others. Place a check mark next to those you think are good questions, and then explain why you think they are better than the ones you did not check.

1. The worker to a woman in the hospital waiting room whose baby just died of pneumonia: “How old was your baby?”

2. The worker to a woman who is grieving after her husband died in a hunting accident: “Could you tell me about your husband?”

3. The worker to a teenage boy who is afraid of failing a math course and losing an opportunity to get a scholarship: “Can you tell me a little bit about this math course?”

4. The worker to a young woman who has just discovered her best friend and her boyfriend have been seeing each other behind her back: “Can you tell me something about your best friend?”

5. The worker to an elderly woman whose dog of 15 years has died: “Couldn’t you get another one?”

6. The worker to a man who is requesting food for his family after running out of unemployment compensation and being unable to find a job: “Can you describe the sort of work you would be looking for?”

7. The worker to a woman in a shelter who has been out searching unsuccess- fully for a house or apartment for herself and her two children: “Where all did you look?”

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198 Section 3 effective Communication

8. The worker to a single mother who has been referred for parenting skills training: “Could you tell me something about the problems you have been having with Johnnie?”

9. The worker to a man with intellectual disabilities whose mother, with whom he has always lived, died unexpectedly: “What did your mother die of?”

10. The worker to a woman who was accosted and assaulted in her neighborhood and is afraid of calling the police: “Can you tell me a little bit about what happened tonight?”

exercises III: Opening Closed Questions

Opening Closed Questions I

Instructions: Following are some vignettes in which the worker asks closed ques- tions. Write an open question you think might work better in each situation, and be prepared to tell why you think the closed question is not useful.

1. A human service worker in the emergency room is talking to a man who was hit on the head before he was robbed. He seems to be having trouble getting the story out, but he wants to tell the worker everything that happened. The worker has been with the man a long time. She thinks that it is late and that the man ought to get to bed and rest now. The worker cuts off the discussion with, “Aren’t you tired, Mr. Jones?” What open question would you have asked Mr. Jones to help him wrap up his story?

2. The human service worker is trying to learn what happened that resulted in Mrs. Peters being without housing. Mrs. Peters says she has been “on the street a while now.” The worker asks, “Have you been on the street for 2 years, 3 years?” What open question would you have asked to learn more about what happened to Mrs. Peters to make her homeless?

3. The human service worker is on the phone with a woman, the victim of child abuse. The woman tells how she has felt recently, how she needed to call, and then sighs and says, “Oh, I don’t know how to begin.” The worker asks, “Did your father do this to you?” What open question would you have asked to help the woman start telling the story in her own way?

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Chapter 9 Asking Questions 199

4. An older man has just lost his job after repeated warnings to come to work sober and seek help for his alcohol addiction. He has decided that he should get help now. “Too little, too late,” he says with resignation. “I should have been here 6 months ago.” The worker asks, “Why did you ever let it get to this?”

5. A child is talking to a youth worker while he waits for his mother to get a place to stay. “We’ve lived in 16 places,” he announces, “and I’m only 7.” The worker says, “What school did you go to last?” What open question would you have asked to help the child talk about what all this moving has been like for him?

6. A man calls a hot line and tells the mental health worker he wants to die. The volunteer asks, “Does this have to do with being abused as a child?” The man is startled and says, “Why, uh, no. Not really.” The worker asks, “Well, what’s the problem?” What open question would you have asked to help the man talk about what was troubling him?

Opening Closed Questions II

Instructions: Put yourself in the place of the worker in the following vignettes, and decide what question you would ask in each situation. Write an open question that you think might work better than the one asked by the worker, and be prepared to tell why you think the closed question is not useful.

1. A worker is interviewing a man in the food bank. He tells the worker that he and his children have not eaten for 24 hours and that he has spent most of that time getting referred around town until he finally got a voucher to come to you for food. The worker asks, “Why don’t you have any food?” What would you ask?

2. A woman is referred to the social service department in a large hospital after hav- ing a stroke. She is somewhat incapacitated and has had a lot of therapy while hospitalized. Now she is going home and needs therapy at home. The worker asks, “What kind of therapy do you want?” What would you ask?

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200 Section 3 effective Communication

3. A 16-year-old girl was brought in by her parents after they caught her and some of her friends huffing glue and gasoline. The girl is reluctant to talk and seems a little petulant about being brought in. The worker asks, “Huffing glue. So tell me, you did it to get high, to be one of the crowd, to be smart? What would you ask?”

4. A man and woman have been referred by the county Children and Youth Services for parenting skills training. They are poor and have had their four children re- moved from the home. They have been told the children will be returned when they complete the course and demonstrate they can use the skills they learned in supervised visitations. The worker asks, “Are your children good kids?” What would you ask?

5. An elderly woman has been having trouble caring for herself in her own home. Twice now, in the middle of the night, she has called an ambulance and has been taken to the hospital for chest pains. When her heart is checked, she is found to be in good health, if a little frail. The worker who is looking into what could be going on asks, “Are you afraid to stay at home alone?” What would you ask?

6. A young woman and her baby have been given a voucher for temporary shelter after she lost the apartment in which she was living. She was evicted for back rent, and her rent fell into arrears only when she was laid off several months ago. She has worked, but she cannot earn quite what she was making before. The worker doing the intake interview asks, “What kind of work have you been do- ing?” What would you ask?

exercises IV: Try Asking Questions

Instructions: Look at the case histories that follow and, for each one, write four closed questions and four open questions that you might ask the client.

1. Annette came to your office needing her prescription filled. She was in Marywood Hospital, a private mental hospital, and was discharged on Tuesday. She was given prescriptions, but has no money to fill them. She has no job and probably is eli- gible for prescriptions paid for by the county. You open a case on her.

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Chapter 9 Asking Questions 201

Your Closed Questions to Open Her Case Are:

1.

2.

3.

4.

Your Open Questions to Learn More about Her Are:

1.

2.

3.

4.

2. Marie was a client of a partial hospitalization program. She was loud and de- manding, but she often felt hurt upon learning that others were afraid of her or reacted to her as if she were angry. As a result of an encounter in the partial pro- gram, she is sent to you, her new case manager, to see if there are ways to help her that might work better. You need to understand more clearly what has hap- pened from her perspective and what sort of program she might fit into.

Your Closed Questions to Become Acquainted with Her Case Are:

1.

2.

3.

4.

Your Open Questions to Learn More about Her Problems and Desires for Treatment Are:

1.

2.

3.

4.

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Chapter 10 Bringing Up Difficult Issues 203

Bringing Up Difficult Issues

Introduction

There will be times when you have a concern about something the person has said or done. You may be concerned for your client’s well-being, or you do not want your client to do something harmful or continue to behave or think in ways that are destruc- tive. Perhaps, from your perspective, there are some other avenues the person might consider or pursue in order to resolve her problems.

Confrontation

The term confrontation is generally thought to mean bringing something into the open that needs to be addressed in a harsh, aggressive manner. Confrontation as such is used to address issues that the client may be avoiding or denying. There are differ- ent schools of thought about whether or not this kind of confrontation is useful and what confrontation techniques to use with different populations. Some (Bratter, 2008, 2011) advocate a harsh, reality based method that forces people, particularly teens engaged in self-destructive behavior, to consider their actions. Polcin (2009), writing about individuals with substance abuse issues, argues that some workers feel these tactics are best used to “break down denial with the use of argumentation or even personal attacks” (p. 505). There are those who feel that the effectiveness of this kind of confrontation is not well known due to a lack of empirical research. For these work- ers confrontation would consist of “nonjudgmental feedback” (Polcin, 2009, p. 505). In other words, the best way to confront others—and whether or not confrontation works is not clearly known—leading workers to “rely on their own experience and intuition when using confrontation” (Polcin, 2003, p. 179).

On the other hand, there are those who argue that, “confrontational counseling has been associated with a high dropout rate and relatively poor outcomes” (Miller and

C h a p t e r 10

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204 Section 3 effective Communication

Rollnick, 2002, p. 7). They argue for a different approach that is more supportive and empathic and contend that harsh confrontation techniques cause the other person to become defensive and resistant to what the worker has to say.

Exchanging Views

We are not counselors, but case managers, and using confrontation, which most researchers agree is a therapeutic tool used in counseling, a strategic intervention in the counseling process, is not something we would do as case managers. Clearly when and how to confront and who can benefit from confrontation are best left to counsel- ors and therapists with years of training.

In this chapter we will look at other ways to bring up issues that need to be con- sidered in a way that the other person can hear, experience as an effort to be supportive, and can use in resolving his problems. We want to think of this technique in four ways:

1. We are collaborating with an equal on how to solve a problem. We have ideas or concerns and other people do as well. Both are equally valid for consideration.

2. We are making a contribution to the resolution of the problem but the other is free to reject the contribution as not useful to him or her at this time.

3. We are making our contribution without a personal need to have the problems resolved the way we think is best. Therefore, we are matter-of-fact in bringing up our point of view.

4. We are offering our ideas tentatively because we don’t have all the answers and we are not always right. We stand open to being corrected or hearing another perspective.

What this means is matter-of-factly bringing something out in the open to gain a better understanding and perhaps to help people make meaningful changes or take important new steps. When you bring up your point of view, you are holding up the reality as you see it for the other person to consider. The client is in no way obligated to see things your way, but now both points of view are known and considered. Many opportunities to grow and make constructive changes will be discovered when you engage in a collaborative exchange of views.

The decision to bring unspoken issues into the discussion is another strategic decision. This chapter examines when bringing up these issues might be a useful tool to help you and your client explore differences and resolve possible conflicts.

When to Initiate an Exchange of Views

Discrepancies

There are times when a person will communicate two different messages. Pointing this out can help the person see the discrepancies and can offer an opportunity to look at the situation and at themselves in another way. Some examples of discrepancies follow.

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Chapter 10 Bringing Up Difficult Issues 205

The Person Says One Thing but Does Another. Dalia tells you that she really wants to go to the job-training program and that getting a job is a top priority for her, but she does not register for the classes. On the other hand, she has numerous excuses for not registering, some of which do not seem entirely believable.

Here is what you might say to Dalia: “There have been three job fairs in the last 6 months and we had the applications for a couple of job readiness workshops, but I’m getting the feeling that this isn’t the direction you want to go right now. Can you help me out with this?” Clearly the worker is not sure about Dalia’s intentions and is asking Dalia to share her view on the matter.

The Client Has One Perception of Events or Circumstances, and You Have Another. Harold thinks you are uncaring and self-involved. He got this idea because you did not come to work the Friday after Thanksgiving even though the office was open. He was off work that day, and he wanted to make an appointment with you so that he would not have to miss work at another time. Your perception is different. To you it was reasonable to be off work the Friday after Thanksgiving because there was only a skeleton staff working that day. You also needed to take a day off before the end of the year or you would have lost some of your accumulated time. Clients rarely come in on this date, and there was a crisis team to cover any cri- sis that might have come up. To Harold you seem uncaring, while to you your actions seem reasonable.

The Client Tells You One Thing, but the Client’s Body Language Sends a Very Different Message. Andrea tells you that she is “fine,” that she feels “okay,” and that “everything is all right.” She looks, however, as if the opposite is true. She speaks in a monotone, looks at the floor as she speaks, and appears depressed and disheveled. These are clues that the spoken message and the unspoken message do not match.

The Client Purports to Hold Certain Values, but the Client’s Behavior Violates Those Values. Paul tells you he “likes everyone” and “accepts” every- one. He tells you ethnic differences are unimportant to him and he finds them enrich- ing. In one of his meetings with you, he tells a decidedly racist joke that obviously denigrates a minority group.

All of the examples discussed here are situations that contain discrepancies that deserve to be addressed. Doing so will help to clarify the issues and help you and the other person come to understand one another’s point of view. Often ignoring discrep- ancies interferes with understanding between you and your client because of conflict- ing perceptions.

Other Reasons to Begin an Exchange of Views

There are other reasons besides discrepancies for exchanging viewpoints. You can do this to bring out in the open behavior or communications that seem to interfere with clients meeting their goals. Following are some examples of such situations.

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206 Section 3 effective Communication

The Client Has Unrealistic Expectations for You. Marcy expects that you will drop everything to see her or to take her phone calls. She does not want to see anyone else in the agency and does not think she should have to see anyone else at night. You are her case manager and she wants you to be there when she needs you.

The Client Has Unrealistic Expectations for Him- or Herself. Miguel has been in a partial hospitalization program for a number of months and has been sick for about 4 years. Stress seems to trigger his psychotic symptoms, and regulating his medication is difficult. He is very good at cleaning and janitorial tasks around the cen- ter, and there is a good supervised janitorial program for clients in which they hold a regular job and clean actual establishments. Miguel can have a job there but he is set on going to work at the highway department and getting a job “driving a steamroller.” He applies for the job repeatedly but gets no response.

The Client Asks for Assistance, but Actions Indicate the Client Is Not Interested. Serena asks you to help her find suitable housing so she will not have to stay at the shelter any longer. You have some leads she could pursue, but she breaks appointments, calling in to say she was detained and will reschedule. She does not follow up on the leads you give her, and the two apartments she went to see that appeared suitable she turned down for minor problems, refusing to live there.

The Client’s Behavior Is Contradictory. Art comes in to group and tells the group he will stop drinking. He never misses AA meetings, gets a good job, and begins to help others stop drinking. Later you learn that he is actually drinking in spite of what he says in group and at AA meetings and that he goes to AA on Tuesday and Thursday and to his favorite bar on Friday and Saturday nights. Art’s behavior is contradictory in another way. While he talks to newcomers in the group about how helpful it is to stay in group and how wonderful the agency is, he has been denigrating a certain member of the staff outside the building where he goes to smoke during the break.

The Client Is Engaging in Behavior That Appears Destructive. Claudia has been cited by child welfare several times for leaving her two children under the age of five alone during the evening while she goes out with friends. She tells you that she does not want to lose her children and that she does take care to see that they are in bed before she goes out. However, her behavior is viewed as endangering her chil- dren’s welfare and there is every possibility that the child welfare agency will remove the children if Claudia’s neighbors report her again.

The Client Is Looking for Solutions to a Problem. Marcus needs a place to stay after being in prison for 4 years. He seems to be floundering about where to look and where to start. For now he is “crashing” on the couch at his brother’s apartment, but the apartment is small and with the brother’s wife and two children there Marcus doesn’t think this is a good solution. He tells you he has talked to “some people who know a guy who has some apartments over on 19th Street.”

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Chapter 10 Bringing Up Difficult Issues 207

Using I-Messages to Initiate an Exchange of Views

Because the viewpoint or the perceived problem is yours and the observations are your own, your exchange should begin with or include a reference to you. The term used by Dr. Thomas Gordon for these statements is I-messages because they contain the words I and me. The exchange is not helpful, as we have seen, if statements con- tain the accusatory you. Figure 10.1 shows some examples of correct and incorrect I-messages to demonstrate the difference between them. The first example consists of messages to a client who was late on Tuesday; note the use of I in the correct ver- sion and the use of you in the incorrect version. The second example demonstrates a worker’s concern for what her client is about to do.

To a client who was late on Tuesday:

Correct: “I’m concerned about when we got started on Tuesday morning. Starting late got my day behind more than I wanted, and I spent a lot of time trying to catch up. Could we look at your scheduling and mine and see if there is a way we can start on time?”

Incorrect: “You were late on Tuesday, and you held me up. My whole day was behind, and I spent a lot of time trying to catch up. Can you get your times straight so this doesn’t happen again?”

I-messages broken into the four parts:

Correct: (1) “I’m concerned about when we got started on Tuesday morning. (2) Starting late got my day behind more than I wanted, and I spent a lot of time trying to catch up. (3 & 4) Could we look at your scheduling and mine and see if there is a way we can start on time?”

To the client who is distressed over having to go before the District Justice:

Correct: “I guess it just seems to me that you could get in more trouble if you follow through on your plan to give the District Justice a hard time about this. I’m thinking it might cause him to be even tougher on you. Let’s look at this and see if there is some other way to handle this.”

Incorrect: “If you go out there and give the District Justice a hard time, all you are going to do is get yourself in a lot of trouble. My advice is to cool down and just go in there and listen to what they have to say.”

I-messages broken into the four parts:

Correct: (1) “I guess it just seems to me that you could get in more trouble if you fol- low through on your plan to give the District Justice a hard time about this. (2) I’m thinking it might cause him to be even tougher on you. (3 & 4) Let’s look at this and see if there is some other way to handle this.”

FIgUrE 10.1 examples of I-messages

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208 Section 3 effective Communication

A complete I-message usually contains four parts:

1. Your concerns/feelings/observations about the situation expressed in a nonblam- ing, matter-of-fact manner

2. The tangible outcome you believe you see as a result or the possible conse- quences for the client

3. Your suggestions or thought concerning all of this, offered tentatively as a contri- bution to resolving or improving a situation

4. An invitation to collaborate

The second part of Figure 10.1 provides more examples of messages given to cli- ents, with each message broken into the four parts. Compare the correct and incorrect messages. Note the following about the incorrect ones: They begin imme- diately with the accusatory “you” rather than “I,” and they contain no invitation to the client to collaborate on a solution (in the second example, the worker gives advice instead).

The Rules for Offering Your Point of View

There are ways and times to talk with people about the issues that concern you. An important goal is to do so in a way that allows people to hear you and make use of what you have said (Strong and Zeman, 2010). We all benefit from the feedback of others, but the manner in which it is given often interferes with our ability to accept and use that feedback.

The following text discusses rules for making I-messages less threatening and more acceptable to the listener. Figure 10.2 contains examples of correct and incorrect messages for each rule. As you read about each rule, examine the sample messages in Figure 10.2 under the heading for that rule. Note that in the correct messages the speaker emphasizes “I” and “me,” taking responsibility for the observations, ideas, and concerns, whereas in the incorrect messages, the emphasis is on “you.”

Empathy. Inviting another person to consider your point of view needs to originate from the empathy you feel for the other person and their struggles with problems (Strong and Zeman, 2010; Leaman, 1978). Part of being empathic is being able to sense how the other person will feel when you begin to express another point of view. Perhaps what you have to say is something that is painful to hear, hard to con- sider under the circumstances the client is experiencing. Leaman (1978) writes that when we express our concerns what we say “must emerge from a genuine empathic concern” (p. 630). Leaman goes on to point out that when we put our views out for consideration it should be “an act of caring” for the other person and motivated by “feelings of caring and commitment” (p. 631).

If your concern invites others to examine themselves, their behavior and their choices, this can be difficult. What impact will your bringing up your viewpoint for consideration have on your relationship with the client? Before you bring up your ideas and concerns, consider how this will affect the other person and the relationship you share.

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Chapter 10 Bringing Up Difficult Issues 209

Empathy

To a person having trouble keeping his food stamps:

Correct: “It sounds like this has been so frustrating for you. I’m just thinking that maybe we could make it a little less frustrating if we called down there and asked them what they want you to do to keep your food stamps. What do you think?”

Incorrect: “We can just call down there and find out what they want you to do about keeping your food stamps.”

To a person who leaves her children at night while she goes out with friends:

Correct: “I wonder if your leaving the kids in the evening when you go out with friends isn’t seen the same way by the neighbors and Child Welfare. I’m thinking that they probably think that leaving the kids like that is neglect- ful and that is why they call Child Welfare. What are your thoughts about why the neighbors are doing this?”

Incorrect: “Leaving kids alone at night is neglectful and that is why the neighbors call Child Welfare and that is why Child Welfare is threatening to take the kids away.”

Timing

To a person having trouble getting a job in her field:

Correct: (Said during the third contact) “You know I’m wondering if part of the rea- son you are having trouble getting a job might have to do with the inter- view itself and how others are viewing you. I’m thinking maybe we should look at ways to help you come across as a serious candidate. What do you think?”

Incorrect: (Said during the first contact right after the client has expressed a concern that she is always turned down for jobs in her field. The worker doesn’t know her well enough to judge whether she is serious or not.) “You know I’m wondering if part of the reason you are having trouble getting a job might have to do with the interview itself and how others are viewing you. I’m thinking maybe we should look at ways to help you come across as a serious candidate. What do you think?”

Be Matter of Fact

To a person whose goals are unrealistic for the present:

Correct: “Here’s what I am thinking about this degree in biology. It just seems to me that some of your goals are a bit further down the road for you. I’m wonder- ing if we could look at some preliminary steps for you to take first to help you get ready. What do you think?”

Incorrect: “You’re not ready to undertake a degree program.”

FIgUrE 10.2 examples of I-messages based on rules for confrontation

(continued )

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210 Section 3 effective Communication

FIgUrE 10.2 (continued)

Be Tentative

To a person who may not be seeing all of the issues with his mother:

Correct: “I guess I’m wondering about this problem you’re having with your mother. I could be wrong, but when you describe the way she talks to you, it sounds to me as if she is angry for some reason. Do you think we should look at that? What do you think?”

Incorrect: “It seems to me your mother is angry at you.”

Focus on Tangible Behavior or Communication

To a client who says she is fine but looks depressed:

Correct: “Allison, it seems as if you are feeling pretty blue about things. Things have been pretty rough lately. I’m thinking maybe we should talk about your mood and how you are feeling. What are your thoughts about this?”

Incorrect: “You look depressed. What’s wrong?” or

“I see you as depressed. I’ll set up an appointment for you to see the doctor.”

Take Full Responsibility for Your Observations

To a person who needs housing but is doing little to obtain it:

Correct: “I think what is bothering me right now is that it seems as if the sessions we have together to get you better housing aren’t as important to you as I first thought. What I mean is that to me it seems you have some other more im- portant priorities in your life right now. I might be wrong. I’m basing this on the fact that you never went to see the three apartments that were available to you. Can we talk about where you are right now with housing and where we should go from here?”

Incorrect: “Because you never went to see those apartments, I can see you don’t care about housing.”

or “The way it appears, housing certainly isn’t a high priority for you. You never followed through.”

Refrain from Accusing

To a person who has unrealistic expectations for you:

Correct: “I’m getting the feeling that you would like me to be available to you whenever you call or come in including evenings and weekends. I could be wrong about this. It is just the way it looks to me right now. Can we talk about what your expectations are?”

Incorrect: “I think you think I should be here for you 24 hours a day and that is unrealistic.”

Refrain from Anger

To a person who is having trouble maintaining sobriety:

Correct: “I’m really concerned that you are drinking when you are away from the program and not talking about these relapses in the group. This is pretty important to me and part of that is probably because I think it makes you seem untrustworthy to others in the group. How do you see this?”

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Chapter 10 Bringing Up Difficult Issues 211

Incorrect: “You can’t come to group and lie to people about your drinking. You’ve been drinking outside group and you’re lying about it when you don’t bring it up. I put my time and my energy into these groups and into helping peo- ple like you and you do this behind my back?”

Refrain from Judgment

To a person who needs permanent housing but is not pursuing it:

Correct: “Can we take another look at your priorities and see where housing for you and your children fits in? I was under the impression that this was pretty high on your list, but you haven’t kept the four appointments we had to discuss it. Maybe we need to look at this differently. Let’s talk about this.”

Incorrect: “Housing is not your top priority. I thought it was.”

Do Not Give the Client a Solution

To a person having trouble remembering appointments:

Correct: I need to see if we can get this appointment problem cleared up. My sched- ule gets all off when you forget to come in. Let’s see if there is a way to resolve this.”

or “There probably are some different ways we could approach this appoint- ment problem. I have some thoughts, and you probably do too.”

Incorrect: “Go get an appointment book. Write all of our appointments in the book, and that way you won’t forget.”

or “You should get an alarm clock that works and have your landlady call you up every morning. That way you can’t miss.”

Always Collaborate

Correct: “How can we look at this differently?” or

“What do you think we can we do to change this?” or

“Is there something we should be doing differently?” or

“How can we resolve this?” or

“Let’s look at this together.”

Incorrect: “You need to do things differently.” or

“You need to change things.” or

“I think you need to figure out how to handle this thing.” or

“You need to find a solution here.” or

“You better take a good look at this yourself.”

FIgUrE 10.2 (continued)

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212 Section 3 effective Communication

Timing. When you listen to the other person you may begin to formulate ideas or concerns that you feel need to be expressed. It is important to know when to do this. There are two factors that are important. First, the relationship must be developed before you introduce your points. There needs to be rapport and a sense of trust that exists for the client with regard to you as his or her case manager (Strong and Zeman, 2010). Never begin an exchange of views before you have established good rapport with the other person. Leaman (1978) writes that “rapport is essential” and stipulates that the client needs to see the case manager as “a helpful person” first (p. 632).

The second factor involves when in the developing relationship would you introduce your views. Although you may be able to see what issues are involved and wish to introduce a different point of view during the first interview, that is rarely effective (Leaman 1978; Polcin, 2003). The relationship needs to be well established before you invite an exchange of views with the other person.

Be Matter of Fact. Do not become excited or judgmental or petulant. Refrain from using words or phrases that are derogatory or denigrate people and the choices they have made.

Be Tentative. This is particularly important. You could be right or you could be wrong in your observations, but this is not a competition to see who is right and who is wrong. What you are putting forth for consideration might not work from the client’s perspective. For that reason, it is not helpful to present your ideas as though they are true or right.

What does tentative sound like? Use phrases such as, “I’m just wondering if . . . ,” “I’m thinking that maybe . . . ,” Do you think that one thing we should con- sider is . . . ,” I could be wrong but let me throw out this idea and see what you think.”

Focus on Tangible Behavior or Communication. Tangible refers to what you can observe or hear. Sometimes when we bring something up for discussion, we tend to be vague about what the actual problem is. We might generalize or just describe our feelings about it. This is not enough information for the client to use to make a meaningful change. For example, a worker might say, “I don’t know. I just think you let people walk all over you. I could be wrong about that but it seems a little like that. What do you think?” This is a nice I-message, but it is vague. It would be better to say, “I don’t know. I just think when Curt took the rent money from you and never paid you back twice and then Jean asked for a loan for her car and you gave it to her it was like they felt they could take advantage of you or maybe that they feel they can use you. I could be wrong about that but it seems a little like that to me. What do you think?” In this second instance the other person gets a lot more valuable information.

Take Full responsibility for Your Observations. If you recognize that what you observed is what you observed and that it is perfectly all right for your observa- tions to be incorrect or different from another’s observation, it will be easier for you to take responsibility for your observations. If you are wrong, the perception can be cor- rected, particularly if you have been very tentative and nonjudgmental.

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Chapter 10 Bringing Up Difficult Issues 213

refrain from Accusing. It may be tempting to blame or accuse the client for the situation. Doing that is not empathic or an act of caring. It is an attack on the other person’s self-esteem. Refrain from doing that because it prevents the person from hearing you. Accusatory exchanges are not between equals because the accuser assumes he is right. Accusations sound like this: “You brought this on yourself when you decided to write those letters.” Or in another instance, “You said these things to the group. You set this up so that we can’t trust you. This is your doing.”

refrain from Anger. Sometimes it is tempting to use hostile confrontation to pun- ish a client who has made you angry. In these situations, you might use public humilia- tion or denigrate the person. In the relationship you hold with clients you have a degree of power. Your words can wound the other, diminish your relationship, and cause the other person to feel defensive. Again, the client will not hear the important message.

refrain from Judgment. No matter how much empathy you feel you have for the other person you really can never know entirely what it is like to walk in their shoes, to face the obstacles they have faced, to have grappled with the life circum- stances they have had. Judgments are generally impossible if you are genuinely tenta- tive when you give feedback. Give your viewpoint carefully and listen carefully to the client’s response (Strong and Zeman, 2010). Polcin (2009) refers to using “explicit but nonjudgmental feedback about the potential consequences” (p. 505) (of behaviors).

refrain from Producing a Solution. Because of your position with regard to the cli- ent, who is already having problems, any solution you give could be seen as imperative. Even the words “should” and “ought” sound like imperatives to the client and are best avoided. What we really want is for people to develop their own solutions. If we have a contribution to make to that process there are ways to do that as noted above. What we don’t want to do is take over or offer our solution as the only one or the best one.

Always Collaborate. When offering feedback or your point of view at the end ask the other person what she thinks about what you have said (Strong and Zeman, 2010; Polcin, 2009). When you have laid out your point of view ask, “What do you think?” or “How do you see it?” This establishes the fact that you see this as a shared search for an answer or a positive change of direction.

Asking Permission to Share Ideas

There will be times when you will want to offer information or suggestions. For exam- ple, suppose you are working with a man who wants to start seeing his children who live with their mother. You have some ideas about how he might go about that. Rather than giving the solution, ask permission to share some ideas (Miller and Rollnick, 2002). You might say, “I have a couple of ideas that might be helpful to you, but I want to be sure it is all right with you to share these now.” Or you could say, “There are some things my clients have done in the past that worked well for them. Would you

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214 Section 3 effective Communication

mind if I shared a few of these with you?” In this way, solutions and advice are given only with the client’s permission, leaving the client in charge of his situation and free to reject the offer of ideas.

The opposite approach would be to simply give the advice or hand out solutions. You could even start your message with I. You might say, “I have found it is better if you stay away from the children until there is a court order for you to see them.” You may feel this is an I-message, but you have given a solution without permission. There is the very real possibility that you could make the client defensive, arguing against the very thing you see as a good solution. On the other hand, your client may appear to agree but actually feels resistance to being told what would be best, a resistance he does not express. It is better to ask permission to share the idea first before plunging in. When giving your ideas, do so tentatively and ask for feedback from the client.

For example, Naoko was working with Paul on housing. Paul, who suffered from schizophrenia and had a problem with alcohol, was not happy with the place he lived. Most of the people there had drinking problems as well, and Paul felt they tempted him to drink more and skip his medications. On the other hand, Paul told Naoko that these people were accepting of his illness, friendly, and often very helpful. Naoko had some ideas about where Paul could move where he might feel secure and have friends, but not be with the people who had problems with alcohol. Before Naoko gave these ideas she said, “You know I was thinking of a couple of places that might work for you if they have an opening. Would you mind if I told you about them?” In this way, Naoko made it clear that the ultimate decision was Paul’s and she was only offering suggestions.

Asking permission to share ideas is a good way to proceed when you may be handling a new case in an urgent situation. There is a problem that needs to be solved immediately and the people involved are looking to you for ideas about how to solve it. Even though this is the first encounter with this person, if you ask permission to share your ideas about how to address the issue, it will be more collaborative. For example, you might have to do a crisis intervention with a person who is having a mental health crisis. The family is distressed, looking to you and your agency for what to do next. Here you might say to them, “There are a few ways we can handle this. Would you mind if I lay these out for you and we look at them together?”

It is always best to have more than one idea to share with clients so that they feel there is a choice. Emphasize that the choice is theirs to make and that they would know best which of these ideas, if any, would work for them.

Advocacy: Confronting Collaterals

There may be times when someone is interfering with the client’s treatment, your ability to interact effectively with the client, or your client’s progress. When this hap- pens you need to speak about what is best for the client. You are advocating for your client when you stand up for that person’s best interests. For instance, a night-shift nurse supervisor in the emergency room took it upon herself to keep the interview room open. Even though the room was there for workers to interview victims of

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Chapter 10 Bringing Up Difficult Issues 215

domestic violence, violent crime, or rape, the nurse would barge in, in the middle of the interview, and try to clear the room. Such situations generally include something someone is doing that:

1. Adversely affects the client 2. Adversely affects your work with the client

In situations like this, you need a firmer message. The message would:

1. Not sound tentative 2. Be pleasant, but firm (smile, but mean what you say) 3. Contain an implied or explicit request for help 4. Thank the other person if they comply

Examples of correct and incorrect messages to the nurse in the emergency room who is trying to clear the interview room are shown in Figure 10.3.

In dealing with other people whom we see as making our work more difficult, it is tempting to throw out the rules and simply show our annoyance or exasperation. The problem with that approach lies in the fact that we need to work with other people and the agencies they represent. In this field, we must be able to communi- cate well with one another if we expect to help the people we serve learn better ways of communicating. Your anger directed toward the nurse in the emergency room can affect relations between your agency and the entire emergency room staff. If this is an important part of your work, such strained relations will affect patient care. Remain- ing firm, but diplomatic, often prevents such problems.

On Not Becoming Overbearing

It is a little tricky to stay where the client is and still express your own concern. Some- times a technically correct I-message is really about your agenda and is not sensitive to the client and where the individual is with the problem at the moment. Such an I-message comes across as intrusive.

To the nurse in the emergency room who is trying to clear the interview room:

Correct: “I need you to help me complete this interview. I expect to need this room for about 45 minutes, and then I will have all the necessary information.”

or

“I can see you want the room. Could you give us another 45 minutes to complete the interview? This must be done before the patient leaves.”

Incorrect: “Oh dear, we’ll only be a minute, and I need this information too. May we stay awhile longer?

or

“I thought we could use this room any time. What seems to be your problem?”

FIgUrE 10.3 Sample messages for confronting collaterals

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216 Section 3 effective Communication

For instance, a woman is suddenly widowed. Her husband died in an accident on Tuesday night. You went to the home as part of the crisis team the night it happened because police said she was extremely upset. Tonight you are doing a follow-up visit. When you talked to her the first time, you learned that she is the second oldest of five children. Her brothers and sisters do not live nearby, and she made no move to call them in spite of your suggestion that she do so and your offer to do it for her. You feel that family can be very supportive at a time like this. You have reached this conclusion because you and your family are close and supportive. In this situation, you might send I-messages like those that follow. The parts that are italicized actually express a view or opinion belonging to the worker and do not leave any room for the client’s perception.

• “I will honor your request; however, I feel you may be avoiding a source of real help.” • “I’m uncomfortable that you don’t want your family to be aware of your husband’s

death. Family support can be very comforting, and I’m sure that they will not be incon- venienced.”

• “I’m not clear about why you want to keep this from your family. I feel that they would want to know.”

• “It seems to me that going through this alone will be very rough for you.” • “I feel that talking to your relatives will be very helpful.” • “I have a problem with you wanting to do this alone.”

Suppose it turns out that some years ago this woman was in trouble. She was a rebellious teenager and left school and ran away from home. Her parents seemed not to care, and when she attempted to return home at age 19, they told her she had caused them enough grief and she was not welcome there. She moved here, went to college, got a master’s degree, and married a local dentist. She feels better off without her family who has never offered her support in the past. She does not tell you all this because she just met you and she does not know you well enough to go into all the reasons why she left home and is estranged from her family.

There are five ways we can make our I-messages ineffective.

1. Using the words “but” or “however” reverse what we have just said supporting the client’s point of view—“I do see your point but . . .”

2. Expressing how we see the situation, using I correctly, but never inviting the cli- ent to describe how she sees the situation “What are your thoughts about this?”

3. Suggesting a solution but not asking the client for his solution. “What ideas do you have that we could use to solve this?”

4. Coming across as the way we view the situation is the only way to view the situ- ation. “I feel this is not something you can handle alone so we need to call some- one for you now.”

5. Failing to consider that there may be extenuating circumstances that you are not privy to.

Think about such possibilities very carefully when you frame an I-message. Be sure that while you speak your concern you leave plenty of room for the fact that you do not know everything and that you could be very wrong. Sounding tentative helps: “I could be wrong.” Or “I am not necessarily right about this.”

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Chapter 10 Bringing Up Difficult Issues 217

Follow-up

When people respond to your ideas or views use your reflective listening responses and open questions to learn more and move the conversation forward productively. For example, you might say, “So in other words you really do not want to call your family after so many years of having no contact with them.” The person can agree, if that is the case and will probably move on to tell you more about her situation.

Summary

Providing our own point of view must be done carefully and with considerable tact. Our goal is to introduce another perspective, and we want the person to be able to hear and use what we have to say. This process also involves listening carefully to what the other person says in response. It is often helpful to ask permission to intro- duce our ideas. Once we begin to express our view of things, it is best to sound tenta- tive and to invite people to respond to the ideas we have raised. We do not want to convey a know-it-all attitude that imposes on the client the solution and viewpoints we think are best.

Video Examples

To view the videos that accompany this book, go to CengageBrain.com.

• In “Helping Tom Solve a Personal Problem,” you can see Danica bring up some difficult issues with Tom as they sort out what Tom needs to do to complete his program.

Exercises

These exercises can also be filled out online at CengageBrain.com.

Exercises I: What Is Wrong Here?

Instructions: Look at the following worker communications, and identify what is wrong with the way each one is expressed.

1. To a person who is drinking and taking tranquilizers: “That’s a risky thing to do!”

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218 Section 3 effective Communication

2. To a person who is driving without a driver’s license: “You’re just doing this to tempt fate.”

3. To a person who is always forgetting to take his insulin: “I’m sick of these so- called lapses of memory. You must want to feel sick most of the time!”

4. To a person who bounced three checks in 3 months because she cannot seem to balance her checkbook: “Go take an accounting course, for heaven’s sake!”

5. To the person who has lamented not spending enough time with his son: “Chil- dren are important. They grow up fast. You only have so long to spend with them when they are kids. You should keep that in mind.”

6. To the person who had trouble completing a high school equivalency exam and is now talking of becoming a doctor: “You need to be more realistic about what you can and can’t do. Think of some other career.”

7. To the woman who has completed 10 weeks in a rape victim support group and is still unable to work or leave the house much, but who says she is fine and get- ting over it: “It doesn’t seem to me like you’re getting over it. If you wanted to get better, you would force yourself to go out more.”

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Chapter 10 Bringing Up Difficult Issues 219

8. To the man who complains about his neighbors but spends time on his porch yelling at the children, which starts neighborhood feuds and tensions: “You’re always yelling at them. Of course they fight with you!”

9. To the woman who has been in a wheelchair for several months following an accident in spite of her doctor’s feelings that she could now be up walking with crutches: “You need to get out of that chair and practice walking. The doctor says you don’t need the wheelchair.”

10. To a child who says the other kids do not like him, but who is always hitting the other children and calling them provocative names: “You’re half the problem, you know. Stop yelling and hitting everyone, and they’ll like you better.”

Exercise II: Constructing a Better response

Instructions: Now go back to the vignettes above and construct a tentative I- message that invites collaboration.

Exercises III: Expressing Your Concern

Expressing Your Concern I

Instructions: In each of the vignettes that follow, you have a problem—a con- cern about something affecting the client. For each of these situations, construct an I- message from you to the client. Be sure to follow the rules for bringing up your point of view. Make certain you sound tentative and ask for collaboration. Use several sentences to soften and put forth your ideas.

1. A woman, who has been a prostitute, recently discovered she is HIV+. She is currently staying in a shelter where you see her. Several nights she comes in drunk and tells you, “Hey, it doesn’t hurt as much this way.” The next day you

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220 Section 3 effective Communication

approach her with an I-message expressing your concern and initiate an ex- change of views.

2. A woman you have been working with tells you her husband is really a dear. He has done many wonderful things for her, and she is feeling guilty about calling you, but he does keep her confined to the house and slaps her a lot. You use an I-message to express your concern and initiate an exchange of views.

3. A man with two children needs temporary shelter. His oldest, a daughter, is old enough to drop out of school; and in the course of placing him, you learn that he has encouraged her to do just that. He tells you he needs someone at home to look after the place, now that they have one, and to see that the younger child is taken care of. You use an I-message to express your concern and initiate an exchange of views.

4. A woman, recently diagnosed with ovarian cancer, is using a prescription medica- tion her doctor gave her to help her with the anxiety of facing the perpetrator in court. Lately you feel she has been abusing her medication. Her speech seems slurred, and you often see her slip one of the pills into her mouth. You use an I-message to express your concern and initiate an exchange of views.

5. A man has been on pain medication for a number of months, prescribed by his doctor for intractable low back pain. Following surgery he continues to feel a need for the medication although he is walking well and is pain free. When his doctor began to reduce the prescriptions for the pain medicine you learned that your client began to purchase heroin on the street. You use an I-message to express your concern and initiate an exchange of views.

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Chapter 10 Bringing Up Difficult Issues 221

6. A woman has not come out of her house since she suffered a major injury at work. Although her doctors say she will be able to return to work if she goes to rehabilitation, she refuses to go and cites her concern for her fragile recovery. You have talked to her many times by phone and invited her to attend support groups at the rehabilitation center where you work and to see a counselor, but she never comes, and you are becoming aware that she is terribly fearful. You use an I-message to express your concern and initiate an exchange of views.

Expressing Your Concern II

Instructions: In each of the vignettes that follow, you have a problem—a concern about something affecting the client. For each of these situations, construct an I- message from you to the client. Be sure to follow the rules for confrontation. Make certain you sound tentative and ask for collaboration. Rather than a single sentence, try using several sentences to soften and put forth your ideas.

1. A man who has been sitting by his wife’s side since she slipped into a coma is weary and has neither eaten nor slept for over 24 hours. You approach him with an I-message expressing your concern and initiate an exchange of views.

2. A woman who is refusing to take medication that would prevent her from having a psychotic episode comes to you and says she is not sure what to do. She does not feel well, but she would like to be able to handle things without medication. You use an I-message to express your concern and initiate an exchange of views.

3. A man whose wife just left has told you he wants to give up his job and simply leave the area, having no further contact with either his ex-wife or his children. You are concerned that he has not had time to think this through. You use an I-message to express your concern and initiate an exchange of views.

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222 Section 3 effective Communication

4. A man on your caseload, addicted to heroin, has been arrested for selling heroin to a minor. You go to see him at the county prison where he tells you that selling heroin was the only way he could support his own habit. You use an I-message to express your concern and initiate an exchange of views.

5. A woman staying in the shelter where you work has left her baby in the care of others repeatedly and gone out. She says she is going to the store or to look for an apartment or a job, but others let the baby lie in the crib and cry. You have had to feed and change the baby on several occasions. You use an I-message to express your concern and initiate an exchange of views.

6. A man is waiting for his Social Security disability check to start. He has a serious heart condition and has been told he should not be out in extremely cold or hot weather. You stop by on a home visit and discover he is out on a cold day shoving piles of snow off the driveway. He tells you it is not that cold and this is not “shoveling.” You use an I-message to express your concern and initiate an exchange of views.

Exercises IV: Expressing a Stronger Message

Instructions: In each vignette that follows, you have a problem with the behavior or actions of someone; this person’s behavior is affecting the goals of your work with the client or is adversely affecting the client. For each vignette, construct a firmer message that explicitly or implicitly requests this person’s help.

1. You are interviewing a man who appears to be quite delusional in the hospital emergency room. The new security officer at the hospital does not seem to un- derstand that the behavior is part of an illness, and he keeps entering the room and asking, as if the patient cannot hear, “Is he giving you any trouble? Do you want me to take care of him?” Your message expresses your need to continue the interview and your need for privacy.

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Chapter 10 Bringing Up Difficult Issues 223

2. You have been working with a man who was beaten and robbed. Because of the injuries, he has been unable to work. His employer calls you several times, say- ing he thinks the man is simply “freaked out” and needs to get over it. The boss tells you that he has told the man this on several occasions, and says that the man just yells at him. You need the boss to understand the severity of the situation, and you feel it would be helpful if he did not keep calling the victim with his negative opinions. Your message expresses your need for the boss to work with you and the client more constructively.

3. You have been working with a child in temporary housing. You have discovered the child is very artistic, and you have found an artist who is willing to volunteer time to teach the child on Saturday mornings. The mother of the child is upset and tells you that it is impossible “the kid has any talent” and that “anyway, he’s got chores on Saturday morning.” Your message expresses your need to see the child’s potential fully realized.

4. You are interviewing a rape victim when her boyfriend barges into the room and demands, “What’s going on in here?” Your message expresses your need to con- tinue the interview.

Note: Do not allow another person in the interview room with the client until you and the client have decided privately whether that person should be there. In other words, do not discuss, in front of the boyfriend, whether the boyfriend or anyone else can stay. Do not exchange glances with the client. In such situations, never ask the woman, in front of the man, if it is all right for the man to stay during the interview. Lead the man outside when you give him your message. Later, when you and the woman are alone, you can ask her whether she would like to have him present, but always make it appear that the decision to have him wait outside is yours. It is possible that she is afraid of him and will feel compelled to agree to his staying if she is asked about it while he is in the room. If she is fearful or embarrassed, the quality of the interview will be compromised.

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224 Section 3 effective Communication

5. An elderly woman is trying to decide what to do about her need for help. The decision is between staying in her own home with assistance, or selling her home and entering a nursing home. She is very torn. You have arranged for help, which seems to be working well, and you visit her each week. During your visits, the woman discusses with you her options. The decision is a difficult one for her. When you visit her, a woman who lives next door invariably appears and offers her advice and expresses her doubts that the woman should be living alone. Your message to the neighbor expresses your feeling that her behavior is not helpful.

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Chapter 11 Addressing and Disarming Anger 225

Addressing and Disarming Anger

Introduction

People do become angry. They express anger and hostility in ways we might find quite unpleasant. We can expect that there will be times when the people with whom we are working will forcefully express their anger. As professionals, it is helpful to view the anger as a clue to other underlying issues or as a clue to problems that need to be resolved. Using the anger to help us better understand the other person is bet- ter than reacting to it defensively or personally. When people are angry, it is not about you. It is about frustrations and concerns in their own lives. If you are an effective, reflective listener, you will hear these underlying causes and feelings, and you will respond in a manner that disarms rather than provokes the anger.

Common Reasons for Anger

When clients are angry, it is often because of one of the common reasons listed here:

• The client is angry about something the agency has done. The agency in which you work will have policies and regulations that you must follow. Sometimes the agency is bound by state and federal laws as well. These laws work better for some clients than for others. Clients who feel that the agency’s policies have caused them to be treated unfairly or with insensitivity to their particular cir- cumstances may react angrily.

• The client is angry about something you have said or done. As noted earlier, there will be times when the client or the client’s friends and relations will have a problem with something you have said or done. Without your intending that it should

C h A p t e r 11

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226 Section 3 effective Communication

happen, a client may completely misunderstand what you have said or may misread your intentions. On the other hand, you may not always be completely tuned in to where the client is at any particular moment and may unwittingly say or do something the client finds upsetting.

• The client is fearful. Many people are frightened by the turn their lives have taken. The changes that have occurred that brought them to your agency may make them feel as though their lives are out of control. They may attempt to reassert control through the use of anger, and they may lash out at you because you are the safest target or the closest person at the moment.

• The client is exhausted. Some clients you see will be exhausted. These people may have been grappling alone with an issue or problem for a long time, or the cir- cumstances they are facing now may be taking all their energy. They sense that they may not be able to carry on, which may cause them to direct anger at you.

• The client feels overwhelmed. Other people feel overwhelmed by problems. They may feel that they cannot handle all that is facing them. Sometimes they feel the extent of the burden is unfair, and so they lash out at you.

• The client is confused. Some people are confused by policies, circumstances, oth- ers’ reactions to them, or the steps they must take to right a difficulty. Rather than admit to feeling confused, some clients become angry and blame the sys- tem or you or your agency.

• The client feels a need for attention. Some people feel insignificant and demeaned. It may have nothing to do with you, and it may very much relate to a lifetime of living in the margins or having one’s problems or contributions trivialized. These people need to feel valued and worthwhile. The problem for you is that your best efforts may not always be good enough. Sometimes such people are extremely tuned in to slights and suspected rejection. They may become angry with you for reasons that you feel are unfair or unwarranted. As always, you are the professional person and need to speak to the condition of the client in a pro- fessional manner.

People become angry for many reasons. Knowing how to disarm anger is impor- tant. It will enable you to move toward a more meaningful dialogue and a better resolution.

Why Disarming Anger Is Important

You cannot be as effective in your work if you are dealing with a client who is angry. The client cannot be expected to move the relationship to another level; but you, as the professional, can be expected to practice the techniques that will allow the relation- ship to move beyond the anger. The major reasons for disarming anger are as follows:

• Eliminates an obstacle to true understanding. Disarming anger diffuses the anger, making it less of an obstacle to true understanding. People who are angry can- not really hear each other. If you are genuinely interested in why the client is

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Chapter 11 Addressing and Disarming Anger 227

reacting in this manner, you need to reduce the anger so that you can better un- derstand what is fueling these strong emotions.

• Shows clients you respect their message. Disarming anger shows the other person that you respect the message even if the way it is expressed is not helpful. By mov- ing to another level beyond the anger, you can indicate to angry clients that their concerns are important to you even when you are having trouble with the way they are addressing these concerns.

• Enables you to understand the problem. Disarming anger allows you to become aware of the actual problem. Only when you have disarmed the anger can you and the client actually address the underlying concern. As clients feel heard and understood, they are more likely to begin to collaborate with you in looking at their problems and the solutions.

• Allows you to practice empathy. Disarming anger allows you to practice empathy, seeing the situation as the other person is seeing it. Disarming anger is an impor- tant part of establishing rapport. If you become angry yourself, you are caught up in your own feelings and needs at the moment. On the other hand, if you think about the reason the person is angry and you speak to that situation or to those feelings, you are responding empathically. This lets the client understand that you are not going to engage in an angry exchange, but you are going to respect the client’s concerns and feelings.

• Focuses work on solving the problem. Disarming anger focuses on solving the issues and problems, and not on who is to blame. Disarming anger techniques do not allow for exchanges of blame. Angry clients may hope for such an exchange with you wherein they blame you and you defend yourself, often by blaming them in return. The purpose of disarming anger is to fix those things that legitimately need to be fixed.

Many people sound angrier than they mean to. They are often anticipating the angry response of the other person. As human service workers, we read anger as a signal that the client’s needs have not been met, and we focus on resolution of the problem that has caused the angry emotions, regardless of whether we think the cli- ent’s anger is legitimate.

Avoiding the Number-One Mistake

Countless times human service workers encounter people who are openly angry. Many of those workers choose to take that anger personally. Taking anger personally is the number-one mistake when dealing with an angry person. It is a foolish mistake to make.

As noted earlier, people become angry for a number of reasons. Some of these reasons have nothing to do with the worker specifically. Other times the anger may be caused by something the worker or the agency has done, and the anger may be rude and denigrating. Nevertheless, beyond disarming the anger, it is important that when you encounter an angry client, you refrain from taking the anger personally.

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228 Section 3 effective Communication

It is not about you and how you feel. It is always about the client and your profes- sional response to the client. A worker who chooses to take the anger of a client per- sonally might end up in a conversation something like this.

client: Where the hell were you on Tuesday?

worker: What do you mean?

client: Where the hell were you? I came in to get a voucher for food, and you weren’t here.

worker: Why are you shouting at me? I wasn’t here, but you don’t have to shout.

client: I do have to shout! You say to come in here for a voucher, and I did that, and you were not even here. Where the hell were you?

worker: Look, Mr. Peters, I don’t have to tell you where I was. If you came in and I wasn’t here, why didn’t you tell someone else what you needed? I’m not the only person who can help you.

client: I get so damn tired of the way you guys act like prima donnas. Who the hell gave you the right to tell all of us when to come and when to go? You say come in, I come in, like a fool, and you decide you’ll just go someplace else.

worker: Well, if that’s the way you feel, you certainly don’t need my help. I’ve spent quite a lot of time with you, may I remind you? You have gotten a lot from this agency. I’m not sure I’m going to put up with this shouting at me.

client: Well, what are you going to do about it? I can tell you that you are a piss-poor caseworker if I want to. I can’t do much else around here, but I can do that!

worker: You’re an idiot. Go out and get the voucher from Mrs. Charles, bring it back here, and I’ll sign it (begins reading papers on her desk).

In this example, the relationship is damaged, and there is an unsatisfactory reso- lution. Bitter feelings remain for both the worker and the client.

There is a better way to handle situations like this one. This chapter will explain how to use a four-step process to deal with anger. The central question you want to ask yourself is this: Can I feel empathic toward this angry person and hear the pain behind all this anger—or am I likely to get into a power struggle with this angry per- son to show I won’t be pushed around? Empathy is the professional response. Power is the unprofessional response.

Erroneous Expectations for Perfect Communication: Another Reality Check

Some human service workers have the erroneous expectation that their clients will give them no trouble. In their view, clients not only will never get angry, but they will follow suggestions, be appreciative, and never raise doubts, criticisms, or resistance. This sort of thinking is a trap, and workers who fall into it often become exasperated or punitive with clients who become angry. Workers who are susceptible to the trap have envisioned themselves as helpful people dispensing good works to people in

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Chapter 11 Addressing and Disarming Anger 229

need. The reality that some people will not want their help, will criticize the help they receive, will show no appreciation or will become angry has not entered their thinking when they chose this field.

We all have had bad times in our lives, and we look back on those times later and think, “I wasn’t myself then.” These times may have been isolated incidents, or they may have been prolonged periods when we were under a lot of stress. The people who seek our help are under a lot of stress. In addition, many of them have problems precisely because they have trouble communicating easily with others. Anger and other forms of negative communication may be all they learned.

Expect anger, disarm it, and treat it matter-of-factly. In this way you will not allow a client’s anger to obstruct your work with the client, nor will you carry com- pletely unrealistic notions in your head that clients won’t or shouldn’t get angry. They will get angry, but you will know what to do.

For example, Jane was a worker in a home for three individuals with mental ill- ness. Kip had a bipolar diagnosis and was doing well. In fact, maintained on his medi- cation, he was pleasant and cooperative. He was working at a local supermarket and seemed about ready to move to an apartment of his own. Then it was discovered that the medication he was taking, Lithium, was adversely affecting his liver. Liver func- tion tests came back showing this deterioration. Doctors immediately removed Kip from the Lithium and placed him on an alternative medication.

Almost at once Kip’s personality turned irritable and angry. He accused Jane of spying on him, and he became erratic about going to work. When the residents in the home went shopping for their groceries, he either sat in the van with his arms folded, refusing to get out, or he created scenes in the supermarket about things he wanted to buy that would have shattered the careful budget he and the others had constructed.

His outbursts in public were embarrassing to Jane, and in the home she often endured a lot of his anger. Jane’s approach was twofold. She actively advocated for a reex- amination of Kip’s medications, and she was firm with Kip but never angry. Many times she told him she understood that he was not feeling like himself. She refused to take anything he said personally. On more than one occasion, his accusations actually made her laugh, and Kip laughed with her, recognizing momentarily how silly his accusations were.

Jane’s superiors, and particularly the treating psychiatrist, all believed that Kip could have become dangerous had Jane not steadfastly refused to escalate the situa- tion or take it personally.

The Four-Step Process

In his book Feeling Good, David Burns (1980) suggests a four-step process for disarm- ing anger. The material in this section is adapted from his book. First, we will look at the individual steps, and then we will look at how these steps work in actual practice.

1. Be appreciative. It is frightening enough to tell people you are angry about some- thing they have said or done. You will put clients at ease if you can say something like “I appreciate your coming to me with this” or “It is helpful to know how you are feeling about this” or “Thank you for bringing this up.”

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230 Section 3 effective Communication

2. Ask for more information. A client who is upset may be skimming the surface of an issue. To understand the issue better, ask for particulars. Do not grill the per- son or sound defensive. You might say, “Can you tell me when this happened?” or “I guess I’m not sure when this happened. Can you help me out?” or “How often did this happen?”

3. Find something with which you agree. Never make up something just to sound agreeable, but see if there is not some little piece of what the client has said with which you can agree. You might say, “I think we have probably done this in the past.” or “I can see where you would look at it that way.” or “There probably was a lapse the day you are referring to.”

4. Begin to focus on a solution. Focusing on a solution should involve collaboration whenever possible. Remember, however, that the client owns the problem; the extent of your assistance is a conscious and strategic decision that you must make.

Begin with your objective point of view. Listen to the client’s point of view. Then decide if you will make changes or leave things as they are. You might, after explaining your point of view, say, “I can see where you thought that. I think from now on I’d like to write you ahead of time.” or “I can see where you thought that. Right now we are really short-staffed, so writing to you ahead of time isn’t really an option. But I’m glad you brought this up. In the future, we will take another look at it.” Own your perceptions and own your decision regarding the problem. Use “I,” not “you.” Let us return to the situation we looked at earlier and see a more effective approach for handling the problem.

client: Where the hell were you on Tuesday?

worker: I’m not sure I know what you mean.

client: Where the hell were you? I came in to get a voucher for food, and you weren’t here.

worker: What time were you here on Tuesday?

client: Oh, about 2:00. You say to come in here for a voucher, and I did that, and you were not even here. Where the hell were you?

worker (using active listening first): Well, this must have been really incon- venient for you. I appreciate your telling me about this. Did you ask anyone else to help you?

client: No, I didn’t. I didn’t know I could.

worker: Sure you can. I can see where you would think I didn’t care about your getting food when you expected me to be here.

client: I know. We didn’t have any dinner Tuesday night. Just potato chips and cheese—oh, and there was a little milk left.

worker: I’m really sorry that happened. Let me see that you get the food you need today, and let me explain better than I did the other day how this

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Chapter 11 Addressing and Disarming Anger 231

works. If I or any of the other workers tell you to come in for a voucher, then you can come right to the office, and whoever is doing the intakes can take your information and see that you get the food you need. This shouldn’t have happened this way, and we don’t want it to happen again.

client: Thanks.

As is rarely the case, all the elements of the four-step process are present in this exchange. In this example, the worker asks for more information with genuine interest (“What time were you here on Tuesday? Did you ask anyone else to help you?”). She goes on to express appreciation (“I appreciate your telling me about this.”). She indi- cates that she agrees with the way the client viewed the situation (“I can see where you would think I didn’t care about your getting food when you expected me to be here.”). Finally, she moves on to focus on a solution (“Let me see that you get the food you need today, and let me explain better than I did the other day how this works.”).

The worker in this example does some other things that make it clear she is not going to take the client’s anger personally. She uses reflective listening (“Well, this must have been really inconvenient for you.”), letting the client know that he is being heard and respected. She also takes some responsibility for the mix-up even though she may actually have explained it perfectly (“And let me explain better than I did the other day how this works.”).

We might change this vignette just a bit. Perhaps the worker actually did explain to the client on the phone before he came in how the agency works. There are many reasons he might not have heard her: anxiety over trying to make sure his kids would eat that night, anger over having to go to the agency in the first place, uncomfortable feelings of helplessness or inadequacy over his inability to fix his situation on his own, and the stress of not eating and having hungry children at home.

Although the worker may not know specifically what has generated the angry outburst, she is fully aware that there are forces at play in this man’s life beyond his need for her to be present when he arrives at the agency. For that reason, she remains respectful throughout the entire exchange, and she moves with genuine interest and concern through the steps of disarming anger. In other words, she does not take his anger personally and feel a need to confront it with anger of her own.

What You Do Not Want to Do

There are a number of things you need to avoid doing. Figure 11.1 contains examples of these things. The incorrect example for each point illustrates what you want to avoid, and the correct example shows you a better way to handle the situation. As you read, refer to the figure and compare the correct and incorrect examples that illustrate each point.

• Avoid becoming defensive. Do not fall into the trap of defending yourself. It is okay to have made a mistake or to be wrong. When you defend yourself you indi- cate that you wish to argue the points the other person is making. It is better

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232 Section 3 effective Communication

Do Not Become Defensive

To a person who feels the worker did not spend enough time with her:

Correct: “I might have cut the interview a little short.” Incorrect: “We don’t have a lot of time around here. I’m doing the best I can.

Do Not Become Sarcastic or Facetious

To a man who works and is frustrated because he needs a later appointment but keeps getting an early morning appointment:

Correct: “I’m glad you brought this up again. We really do need to get this straight.” Incorrect: “Here we go again! Thanks for telling us, again, how inefficient we are.”

Do Not Act Superior

To a woman who thinks her daughter should have different services:

Correct: “We ought to look at this more closely. I’m glad you told me about this. You may be right.”

Incorrect: “The services have been chosen for your daughter by professionals in the field of child development, and they know what it is she needs.”

Do Not Grill the Client

To a man who believes his aunt is being neglected by the agency:

Correct: “Tell me more about what you see happening with us and your aunt. We may need to look at this situation more closely.”

Incorrect: “When exactly did we fail to come out to your aunt’s house? How often did this take place, and did she ever tell us about this before? We need to know specifics before we can determine if this is a real problem. What other prob- lems did you encounter with us?”

FIguRE 11.1 examples of What Not to Do

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to indicate that you want to hear the points the other person is making. If you begin to defend yourself, it makes the other person angrier, and you lose an opportunity to really resolve the problem.

• Avoid sounding sarcastic or facetious. When you thank people for their comments or agree with something they told you, it is possible that you will sound sarcas- tic or facetious. This is especially true if you are feeling defensive. “Thanks so much for telling me” can sound cynical or it can show a genuine desire to un- derstand. Monitor the tone of voice you use in these encounters to be sure your tone of voice is not escalating the situation.

• Avoid coming across as superior. It is all right for you to be wrong in your perceptions or behavior, and it is all right for the client to be wrong too. If you feel especially threat- ened or angry at your clients, it may be tempting to denigrate them in some way, pointing out how little they actually know about the situation or how little experience they have and how much more knowledgeable you are. This is a good time to show that you and the other person need to work together equally to solve a problem.

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Chapter 11 Addressing and Disarming Anger 233

• Avoid grilling the client. In order to better understand the problem from the client’s point of view, you will need to ask questions. However, too many questions can make the other person feel as if she is being cross examined. Avoid grilling the client by asking numerous questions, one after the other, in a doubtful tone of voice. If people are nervous, you will only make their nervousness worse. Most people grill another person in a triumphant attempt to prove the other person wrong. That is not your goal here. Your goal is to genuinely try to understand.

Look for useful Information

It is hard when someone is angry or irritated with you or your agency to really hear what the issues are. However, you can benefit from the feedback you are receiving if you really hear it. Sometimes the client is bringing you valuable information that will help you to make constructive changes in yourself or in your agency.

In one agency, there were a lot of angry clients calling for help. They all had been discharged from a certain program without follow-up services or with follow-up services that had not been confirmed. This often left clients without much-needed medications or months of waiting to be reinstated. The agency was grateful for the clients’ feedback and developed a questionnaire for the receptionist to use when such calls came in. She was instructed to handle each call with a genuine interest in what exactly had happened with each client. Gradually, a picture emerged of precisely what was wrong and how to fix it. In this example, an entire agency benefited from the clients’ feedback. A more efficient operation will keep clients from returning with recurring problems and will save money and time for other clients.

When people are angry they are telling you that something is not working, some- thing is wrong. Listening carefully can help you to discover what that is. It may be something you can change or something happening at the agency or something you have done or it could be something the client is doing that interferes with his care. If you can hear it you have an opportunity to address it.

Safety in the Workplace

Agencies where there are clients likely to be assaultive generally have in place poli- cies and procedures to minimize the danger these people might pose for staff and other clients of the agency. Your agency should have policies and procedures related to how to handle situations that could become dangerous. Who do you call? Where do you conduct interviews where others are nearby? How is the furniture positioned in your office and interview rooms to prevent someone from blocking the door and preventing your being able to leave? If a person has been assaultive or combative in the past what is the agency’s policy related to how that person is served in the future? There is research that indicates that staff training plays a considerable role in preventing dangerous situations and harmful outcomes. Staff training was shown to increase the confidence of professionals dealing with clients who might become

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234 Section 3 effective Communication

assaultive (Kynoch et al., 2011; The Joint Commission, 2010). When you go to work in an agency, look at the policies that are in place and attend any training that is offered. If none of these is offered at your agency ask that they be developed.

The Importance of Staff Behavior

On rare occasions, people become so angry they seem to be about to lose control. Their demeanor moves from rational expressions of anger to increased belligerence, threats to the safety of others, or actual aggression toward people and objects in the vicinity. Research shows that staff people play an important role in defusing these explosive situations (Kynoch et al., 2011). An even tone of voice, continued reflective listening, and relaxed movement work best.

Lisa, a nurse in a community program for the mentally ill, discovered Phil eating lunch one day with a gun lying by his plate. He had been angry about his medica- tions earlier in the day, but that problem seemed to have been resolved. Instead of quietly approaching Phil and suggesting the gun be left with the nurse until the end of the day, Lisa became hysterical. Rushing about the room, she loudly began to clear out the startled patients, thrusting them through the door. “Call the police, call the police,” she kept shouting to other workers. Phil, alarmed by her actions, grabbed his gun and pointed it at her. He began to yell at Lisa, “Just shut up, shut up, before I shoot you. Be quiet.” Lisa dashed from the room and cleared the entire building. Police came from every direction. The area was cordoned off, and a standoff ensued into the afternoon.

Lisa’s loud, hysterical tone of voice, her panic, and her hurried actions all com- bined to make Phil agitated. Before long, the situation had escalated. What Lisa should have tried first was asking Phil to come with her to another part of the building. If Phil left the gun at his place, another worker could have secured it. If he brought the gun with him, Lisa might have said matter-of-factly that perhaps it would be bet- ter to leave the gun with the staff for the time being. If Phil gave her the gun, she could have taken steps to secure it.

Even if Phil were resistant and wanted to keep his gun, the staff could have asked the clients to bring their lunches into the group rooms for after-lunch groups. If they made this request in a tone of voice that indicated that it was nothing out of the ordinary, clients would have complied. In the meantime, police could have been called to come quietly and help to disarm Phil.

In another situation, Jim, a young mental health case manager, was working with Alex. Alex wanted to go into the hospital, fearing that he was getting sick again and would hurt someone. On that particular day, there were no beds, and Jim’s supervisor suggested he help Alex find an alternative to hospitalization until a bed was available. Jim was afraid of Alex, who spent most of that day sitting in the waiting room. Each time Jim explained that no beds were available yet and that an alternative needed to be found, Alex grew more belligerent.

The last time Jim returned to report that there were still no available beds, he did so in what he thought was a very firm manner. Reasoning that Alex seemed about

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Chapter 11 Addressing and Disarming Anger 235

to become uncontrollable, Jim assumed that if he approached him with a firm, supe- rior tone of voice, he could keep Alex from getting any angrier. In fact, Jim’s superior tone was harsh and was heard by Alex as denigrating. He began to shout and pound the wall to demonstrate to Jim “just who is in charge here.”

Clearly the way in which staff react to a person who appears angry and out of control often plays a role in whether the situation escalates or is defused. Remaining matter of fact, practicing empathic reflective listening, and remaining calm are important in main- taining a controlled situation. If you or your clients are in danger, certainly the first thing to do is to secure the safety of everyone. However, situations that escalate because work- ers fuel them—inflaming the client’s anger by becoming loud, agitated, or angry them- selves—can rapidly spiral out of control. Remaining calm and moving deliberately to prevent a dangerous situation from worsening is the responsibility of the professional.

Summary

Disarming anger is an important skill used to preserve your relationships with your clients and to prevent anger from escalating. The goal is to reach an understand- ing about the problems or concerns that are fueling the anger and to resolve those where possible. Becoming angry yourself can only escalate the situation, making real problem solving and collaboration with the client impossible. In previous chapters, you have learned many techniques by which to convey to clients their importance and your interest in what they have to say. Use these to advantage when dealing with a client who is angry. Remain matter of fact, refuse to take the anger as a personal in- sult, and reflect back the underlying concerns and feelings of the client.

Video Examples

To view the videos that accompany this book, go to CengageBrain.com.

• In “An Angry Consumer,” Keyanna practices the skills discussed above when Michelle comes in angry about not being able to fill her prescription. You will see that when Michelle recognizes Keyanna’s genuine desire to help, Michelle becomes less distressed.

Exercises

These exercises can also be filled out online at CengageBrain.com.

Exercises I: Initial Responses to Anger

Instructions: In the examples that follow, formulate an initial response to the anger and criticism you hear. On a separate piece of paper construct your answer, looking at the steps for disarming anger, and use those steps that seem appropriate. The four steps are: (1) thank the person for the comments, (2) ask for more information, (3) find some point on which you can agree, and (4) begin to look for a negotiated solution.

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236 Section 3 effective Communication

1. A man is coming to your agency for assistance after release from a drug reha- bilitation center. He wants you to do more for him than you think is wise. You have been very helpful in ways you could, but you have also insisted he do some things for himself because you do not want him to become dependent. He is frustrated, and one day when you suggest to him that he try to call his lawyer himself, he blows up and yells, “This crazy place, sucking up the taxpay- ers’ money—and for what? I get so sick and tired of your trying to make me do everything when that’s what you’re paid for. A bunch of idiots is what you are! Incompetents! Sure, I can do it myself! If I wanted to do it myself, I wouldn’t have come to you, would I?” What is your initial response?

2. A woman who is in your shelter feels neglected. Twice you are interrupted when you are talking to her because of severe emergencies. You apologize both times and continue your discussion with her, but you are short-staffed and things at the agency are unpredictable. The second time this happens, when you are able to get back to her, she cannot remember what she had been saying. That upsets her. She says, “You all sure can find plenty of reasons to avoid talking to me. Every time I sit down to talk about my case, you get up and run off. Now I can’t remember where we were. I don’t see you running off when you talk to Alice or Cindy. Just seems like every time I need help, well, you have something more important to do.” What is your initial response?

3. Do you see differences between the issues the man is having with the agency and the issues the woman is having with the agency? Are you and your agency more to blame in one instance than in the other? How does your response differ as a result?

Exercises II: Practicing Disarming

Instructions: Following are some opening sentences said by angry clients. It is up to you to develop the exchange, including more information regarding what the client is angry about and the responses of the worker. You do not have to use the disarming steps in any particular order. See if you can add some active listening and open ques- tions as you go along. See if you can put yourself in the clients’ shoes and empathize with their feelings.

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Chapter 11 Addressing and Disarming Anger 237

1. client (talking loudly, and banging his fist on the desk): I have a beef to pick with you! You tell me I’m a mental case and then give me medicine that makes me feel like a nut case.

worker:

2. client (barging past the receptionist to the worker’s office, obviously angry): My kids and I are hungry! Know what that means—to be hungry? We’re hungry and you . . .

worker:

3. client (looking at the worker cynically): So you say the agency is understaffed. Really? Understaffed? Who are all these young girls running around here do- ing nothing? Is it too much to ask that I get an appointment without waiting 4 weeks?

worker:

4. client (Sits down unsmiling, looking past the worker): I am just furious. I’m tired of trying to get into group on the phone. I talk to someone who says there is an open- ing for me. That’s happened three times now. Every time I come in for group the leader says the group is full. A misunderstanding they tell me. Well, what I want to know is how many of these little misunderstandings do you people have a day? Do you think the rest of us aren’t bus