Assessment in Practice

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13 Assessment in Practice I remember this bullheaded psychologist who gave me a smallprint IQ test and told my mother that I was retarded. What he had really tested was my ability to read small print.
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13 Assessment in Practice I remember this bullheaded psychologist who gave me a smallprint IQ test and told my mother that I was retarded. What he had really tested was my ability to read small print. Even my mother knew that his diagnosis was not correct. After all, why would someone give me a small-print test when he knew I couldn t read small print very well? Because I was very determined to go to regular school, my mother told the resistant school officials, You ll have to fight with her. She wants to go here. So this bullheaded psychologist then said to my mother, Well, we ll let her go here so she can learn about failure. So my mother says, Yeah, OK. She only had an eighth-grade education, but she understood intuitively that I was brighter than they gave me credit for. Brenda Premo Western University of Health Sciences STUDENT LEARNING OBJECTIVES 1. To understand the implications and limitations of medical/professionalbased assessment models that utilize a pathological/dysfunctional frame of reference 2. To develop an understanding of the social model of assessment based on the social-ecological model of human development, with its origins in strengths-based practice and the independent living movement 3. To understand the various layers of the social model of assessment, including the biosocial, psychosocial, and social structural domains 4. To learn to apply the social model of assessment, considering multiple systems sizes in the assessment process A routine and critical component of human service practice is assessment. Assessment occurs at all system levels, from the individual and personal to the institutional and societal. Hepworth, Rooney, Larsen, Rooney, and Strom-Gottfried (2005) state that assessment provides a foundation for contracting, goal setting, and interventions and that the effectiveness of interventions is contingent on accurate assessments. Effective assessments are $ CH :07:05 PS PAGE 393 394 HUMAN SERVICE PRACTICE FRAMEWORK multidimensional and purposeful. Assessments can be both process and product oriented. Product-oriented assessments are assessments that result in the creation of a report or document. For example, a medical history and physical are required when patients are hospitalized, and mental status examinations and their results concerning emotional and cognitive functioning are documented. Process-oriented assessments do not necessarily produce a finished product; they are primarily tools used to guide ongoing relationships to direct activities and plans. Of course, assessments frequently overlap in their nature and purpose. In this chapter, we discuss the implications of the types of assessments in which human services professionals engage. We start our discussion by illustrating assessments as products. We discuss traditional pathology-based assessments, which are often required to justify the need for professional involvement. We also discuss the processes of assessment. We then discuss the social model of assessment based on the social-ecological perspective. PROFESSIONAL ASSESSMENTS/EVALUATIONS AS PRODUCTS Assessments of individuals and families can be divided into three components: information and history, impressions and evaluations, and plans. Information and history comprise the what section of an evaluation. What is important to know about the people and situations being evaluated? The second section, the so what section, organizes and gives meaning to the history and information. What is the meaning of the information one has received? The third section, the now what section, outlines plans. Based on the situation at hand, what should be done and what are the desired outcomes? Figure 13.1 provides a skeletal outline of a tool to develop an assessment product. The first component focuses on people s histories, background information, and current situations and the reasons that bring them into contact with practitioners. This information can be referred to as the social history portion of the assessment. Several elements are relevant to this section. Identifying information includes demographic information such as age, gender, ethnicity, onset and type of disability, and living conditions. It also includes the reasons disabled individuals and their families are using professional services. Family background can include information about the person s family of origin; current relationships with family and significant others; and past, present, and anticipated living situations. Social history can include information on a person s educational and work history, friends and relationships, culture, places of residence, substance use history, and involvement with the legal system. Since persons with disabilities are especially susceptible to financial problems, the history should include information on financial $ CH :07:05 PS PAGE 394 ASSESSMENT IN PRACTICE 395 FIGURE 13.1 Assessment and Evaluation Tool I. What? 1. Identifying Information (age, gender, ethnicity, residence, etc.) Reason for admission, clinic visit, or agency involvement Reason for referral to social work 2. Family Background Family of origin or childhood Current relationships Adult family and significant others Living situation past, present, and anticipated 3. Social History Educational history Work history (including military background) Friends relationships Cultural influences Places of residence Substance use history Legal involvement 4. Financial Status Income, expenses, obligations Insurance medical coverage and needs 5. Psychosocial Situation Cognitive status Emotional/psychosocial status Psychiatric mental health history Family reactions, relationships, support, and adjustments Sexuality concerns (e.g., questions, orientation, problems) Judgment/planning behavioral situation Other relevant issues 6. Tools Genogram Ecomap II. III. So What? Impressions 1. Personal strengths and limitations 2. Social supports 3. Resources Now What? Plans 1. Counseling and direct services individual and significant others 2. Social interventions, planning, advocacy 3. Micro, meso, macro interventions 4. Anticipated outcomes $ CH :07:05 PS PAGE 395 396 HUMAN SERVICE PRACTICE FRAMEWORK status. This includes income, expenses, and financial obligations as well as insurance, medical coverage, and costs of medical needs. The person s psychosocial situation may also be important to discuss and may include the person s cognitive and emotional status. Sexuality concerns may be ascertained. Information about the person s history with mental health professionals and the mental health system may be relevant. Family reactions and supports should be considered. Information on the person s relationships within the community may be gathered. Strengths in judgment and planning are also relevant to the person s psychosocial situation. Genograms and ecomaps can be valuable tools for developing comprehensive histories. The information gathered in the social history component of an evaluation varies greatly, depending on each person s circumstances and each person s social and family context. In addition, the settings in which assessments are performed affect the areas highlighted in assessment. For example, the foci of human service assessments in school, hospital, and mental health contexts differ in priority and scope. In the second section of psychosocial assessments, evaluation or impressions, the human service practitioner and consumer consider the meaning of the information gathered in the social history. For example, a person who has had strong family relationships is likely to be able to rely on family for continued support. An individual who has had multiple marriages and divorces might expect less family support than one with strong longterm relationships. An individual from a background of poverty will likely have fewer resources available than a person who comes from wealth. The evaluation section should include information about people s strengths and their realized and potential capabilities as well as their needs and limitations. It considers individuals social supports and their ability to affect people and organizations in their lives. The level and adequacy of personal and environmental resources are also evaluated. The final section of psychosocial evaluations, the plan, is based on the evaluation section. Plans should be explicit and goal directed. In the plan, the person and professional determine desired outputs and outcomes. Outputs may include services that professionals may provide (e.g., counseling, advocacy, referrals) and actions in which consumers may engage. Outcomes focus on the results the consumer and practitioner wish to achieve in their work together. Attention to micro, meso, and macro elements of people s lives is a critical element in effective plans. Five questions that provide a framework for assessment activities can be asked as practitioners develop human service assessments. First, What is the reason for the assessment? This helps practitioners evaluate people s needs and their reasons for engaging in a relationship with a human service agency and professional. Second, What is the scope of the assessment? Scope is determined by a variety of factors, including people s needs, agency $ CH :07:06 PS PAGE 396 ASSESSMENT IN PRACTICE 397 mandates, and social conditions. For example, the reasons for and scope of an employment assessment in a vocational rehabilitation agency differ from those of an assessment performed during the course of family therapy. A third question is, Who receives the information and knowledge gained as a result of the assessment? In an individual and family therapy agency, assessment information is usually kept within the confines of the practitioner and family relationship. However, if family therapy is taking place within a medical and/or psychiatric facility, the information is generally more widely disseminated to other professionals and to third parties. A fourth question is, What are the sources of knowledge that will be needed in order to engage in the assessment? This will determine how information is obtained. Some assessments utilize only one source of information, whereas others utilize multiple sources. Court-ordered assessments for substance abuse offenses may utilize numerous informants as well as court records. On the other hand, assessments for participation in an educational group may rely exclusively on an individual interview. Fifth, What will the assessment be used for? For example, if assessments are being paid for by a third party, especially in managed care settings, a clinical (pathology-based) diagnosed assessment is often necessary to obtain reimbursement (Strom, 1992). Medical and psychiatric settings require pathology-based diagnoses. In contrast, assessments performed in independent living centers focus on consumer definitions of needs and problems. PATHOLOGY AND ASSESSMENT Traditional assessment models focus on the presence or absence of pathology (Schuler & Perez, 1991). For example, medical histories and physicals required when patients are admitted to hospitals determine whether findings are within normal limits or there is pathology. Strengths are not considered. There are several reasons for the diagnostic, problem-focused emphasis in professional evaluations. Persons seeking professional help do so to receive assistance in treating or solving problems. For example, people see physicians to treat or cure illness. Professional training and sanctioning centered on pathology have traditionally driven models of practice. Medical specialties (e.g., neurosurgery, cardiology, rheumatology) concentrate heavily on treating pathological conditions, and there is relatively little emphasis on preventive and health-maintaining specialties (e.g., family practice, epidemiology). Similarly, mental health training primarily focuses not on maintaining mental health, but on treating mental health disabilities. To justify intervention, a DSM diagnosis must be provided. The focus on pathology has been driven, in great measure, by financial interests. Funding is institutionally based in places such as hospitals and nursing facilities, and service providers are paid only after diagnosing and treating pathology $ CH :07:07 PS PAGE 397 398 HUMAN SERVICE PRACTICE FRAMEWORK Certainly, the focus on pathology is essential in many situations (Blotzer & Ruth, 1995). A person taken to an emergency room with multiple injuries from an automobile accident requires immediate assessment and treatment for injuries sustained. Empathy is not particularly a high-priority skill in an emergency or operating room. Similarly, a person experiencing an acute psychotic episode needs immediate protection and treatment. However, an exclusively pathological focus is inadequate in the long term. This is especially true in human services. By attending primarily to problems, assessment can fail to account for individual strengths. A deficiency focus can lead to the devaluing and, in some cases, dehumanizing of people (Cowger, 1994). For example, in reviewing old patient hospital records, one of the authors repeatedly found the notation FLK in the records of children with mental retardation. Upon investigating the meaning, he found that FLK was an acronym for funnylooking kid used routinely to refer to patients with mental retardation. FLK was originally used as a type of medical shorthand, because children with intellectual disabilities can have atypical facial and body features. However, the term FLK devalues the people it supposedly describes. The individual pathology focus also fails to recognize the complexity of experiences and relationships (Salsgiver, 1996). This is illustrated in the case of a Native American patient hospitalized in a rehabilitation center with an acute spinal cord injury. Nurses and therapists became increasingly frustrated with his lateness for therapy and his nonparticipation in the general milieu of the center. They attributed his behaviors to denial, resistance, and noncompliance. They failed to realize that he had been raised in a remote community on a reservation. He was overwhelmed, not just with his spinal cord injury, but by his surroundings. The rehabilitation center employed far more people than lived in his community. He had never owned a watch, yet they expected him to follow a tight schedule. He was a night person, yet he was expected to begin his day at 7:00 A.M. There were also language and cultural barriers. However, the staff focused only on fixing his behavior so they could provide the therapies they determined he needed. A more holistic assessment would have led professionals to assess ways they could change their expectations of him and modify the environment in such a way to better meet his needs while ensuring that he received the medical and physical attention he needed. For example, times for breakfast and therapies could have been modified to meet the demands of his lifestyle. The staff could have taken the time to get to know the patient and learn about his culture. MEDICAL AND SOCIAL MODELS OF ASSESSMENT In the last generation, the adequacy of traditional medical assessments based on pathology has been challenged. For example, Trieschmann (1980) compares two models of assessment and service delivery for persons with spinal $ CH :07:07 PS PAGE 398 ASSESSMENT IN PRACTICE 399 cord injuries the medical model and the learning model. Trieschmann points out that in the medical model, the behavioral equation for rehabilitation success consists of: B f (O p). Behavior (B) is a function of treatments to the organic variables (O) unless [these are] hindered by underlying personality problems (p) (p. 24). In the medical model, an individual s organic, physical, and medical problems are the primary assessment targets. Personality and psychosocial status are assessed in the context of the obstacles they create for the treating professionals. Strengths are not assessed only the absence of pathology. The unit of assessment is the individual, problems reside within the individual, and treatment plans center on fixing the individual. In addition, professionals are responsible for assessment and treatment decisions. While this model may be appropriate in crisis situations, such as during a medical or mental health emergency, it has limited benefit in the long term. Condeluci (1995) discusses the limitations of individual pathology assessments that focus on disabled persons problems and ignore the social obstacles that prevent them from being productive. Condeluci states: Today, in the human service world that surrounds disability, a battery of tests and surveys attempts to identify and predict the economic potential of its clients. These tests look at aptitude, interests, skills, education, and deficits. It is mostly the deficits, however, that cast a shadow on the plan that is set up for the individual (p. 72). Trieschmann (1980) offers a more progressive model of assessment and intervention the learning model and contrasts it to the medical model. She advocates its use in rehabilitation settings, stating, The behavioral equation for rehabilitation success is: B f (P O E). Behavior [B] is a function of the person [P], the organism [O], and the environment [E] (p. 26). In Trieschmann s learning model, person variables include personality style, coping mechanisms, and internal or external locus of control. Organic variables include age, health, and severity of disability. Environmental variables include family support, finances, and public policies. Assessment broadens to include psychological and environmental well-being. Individuals are still the focus, but assessment is used to help professionals determine how to educate clients to function better. Assessments are performed to identify knowledge and skills that clients need to function as independently as possible. Control still resides primarily with professionals, who act as educators. The learning model attends to internal strengths and social variables. It may be appropriate in the initial stages of disabilities, when persons with disabilities and their families are in need of knowledge and skill development. However, it is inadequate in the long run because the perception of problems and needs as well as the control of services still rest with professionals. As long as professionals maintain control, people with disabilities are vulnerable to their biases. For example, Condeluci (1995) observes that in $ CH :07:08 PS PAGE 399 400 HUMAN SERVICE PRACTICE FRAMEWORK the employment arena, people with certain types of disabilities are likely to be stereotyped and that the experts push people with certain disabilities toward job areas thought to be best with disability groups (p. 74). For example, people with intellectual disabilities are often pushed into custodial, dish washing, and bus-person jobs, whereas those with brain injuries are traditionally pushed into repetitive work. Assessment tools and interventions such as aptitude tests can be valuable aids in the quest for economic selfsufficiency. However, this model is similar to other models in that it focuses primarily on the individual s deficits and possible interventions to overcome problems. A social rather than individual approach to disability is the approach that best meets the needs of persons with disabilities. Hahn (1991) labels this approach the minority group model and states that social stigma is the major problem facing persons with disabilities, which is best addressed through civil rights rather than social services. The minority group model also alters the view of the disabled person as defected or deficient.... [The] call for improvements in social services is a step in the right direction, but it should be expanded to include civil rights as the major focus for improving the lives of the disabled (p. 17). Condeluci (1995) emphasize
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