CASE MANAGEMENT: EFFECTIVELY WORKING WITH CLIENTS

1. CASE MANAGEMENT: EFFECTIVELY WORKING WITH CLIENTS Nonprofit Learning Point March 19, 2014

2. AGENDA Introductions / Overview Case Management Engagement Motivational Interviewing Crisis Intervention Trauma-Informed care Professional Boundaries Self-Care

3. INTRODUCTIONS On an index card write 3 things you do to take care of yourself. Name Where do you work? What is one thing you do to take care of yourself?

4. COURSE OBJECTIVES Demonstrate rapport development and maintenance skills consistent with the philosophy of Motivational Interviewing. Demonstrate basic skills in enhancing client motivation. Identify steps in preventing and managing crisis and conflict. Understand trauma-informed practice and how it might be applied in practice. Identify appropriate professional boundaries. Identify risk for burnout and steps to prevent it.

5. CASE MANAGEMENT

6. CASE MANAGEMENT An approach to social service delivery that attempts to ensure that clients with multiple, complex problems receive the services they need in a timely, appropriate fashion. The range of client needs within these populations includes social relationships, housing, income support, medical care, job training, recreation, life skills development, counseling, and medication

7. CASE MANAGEMENT ACTIVITIES Ensuring Service Accessibility for clients Clinical Interventions Client engagement Assessment, Planning and Intervention Environmental Interventions Linkage Mediation between agencies and collaboration with other professionals Monitoring / Reassessment Transitions between service settings

8. CM Activities (Cont.) Environmental Interventions (cont.) Advocacy Social action Representation of client interests Promotion of empowerment Resource Development (including agency policy formulation) Evaluation (of all services provided

9. THE CASE MANAGER-CLIENT RELATIONSHIP This is the sustaining link between the client and the external world, providing an environment of safety for the client. Within that context, the client can: Experience structure as an antidote to disorganization Appreciate the significance of internal and external limits in pursuing goals Learn that that help is available for most problems. Improve clarity of perceptions Experience cognitive and experiential learning Enhance self-esteem through success experiences

10. CASE MANAGEMENT SKILLS Differentiate biological and psychological aspects of functioning Appreciate the effects of social factors on a client’s sense of competence Make ongoing judgments about the intensity of involvement with a client (manage boundary issues) Recognize a client’s fluctuating competence and changing needs Help family members cope with their troubled relative

11. REFLECTIVE LISTENING Listening to what client says, and what client MEANS Checking out your assumptions Creating an environment of unconditional positive regard Remember: Be careful of tone Don’t judge, criticize, or blame You are not necessarily agreeing, you are just listening

12. MOTIVATIONAL INTERVIEWING

13. MOTIVATIONAL INTERVIEWING A client-centered, directive method for enhancing motivation to change by exploring and resolving a client’s ambivalence Ambivalence, or feeling two conflicting ways about the same thing or person, is both normal and ubiquitous Motivation is conceptualized as an interpersonal process, not as a client characteristic The question is never “Why isn’t this person motivated?” but “For what is this person motivated?”

14. STAGES OF CHANGE Precontemplation - The client is not yet considering change; does not see him or herself as having a problem Contemplation - High ambivalence; the client both considers and rejects change; vacillates between reasons to change and reasons to stay the same Preparation- Client accepts the need to do something about the problem. At this point he or she may enter into action or slip back into contemplation

15. Stages of Change (Cont.) Action - The client engages in specific actions to bring about change in the problem areas Maintenance- The client attempts to maintain the changed behavior and avoid the problem behavior. Relapse- Revision back to the problem behavior. This is normal, especially when the client is trying to change long-standing behavior

16. THE NATURE OF CHANGE Change can occur quickly Change is dependent on the client’s faith in its possibility The attributes of the social worker are highly significant to the change process A client’s arguing for change increases the likelihood that it will occur In order to change a person must be: Willing (seeing the importance of change) Able (confident about change) Ready (to make a priority of change)

17. PRINCIPLES OF MOTIVATIONAL INTERVIEWING Express empathy - acceptance facilitates change Develop discrepancy (between how things “are” and “should be”) – let the client present arguments for change Roll with “resistance” - avoid arguing Support self-efficacy - the client’s belief in the possibility of change

18. CHANGE AND “RESISTANCE” Resistance is defined as speech that signals movement away from a particular kind of change. It is characterized by arguing, interrupting, negating, and ignoring The client’s “resistance behavior” is a sign of dissonance in the worker-client relationship. Resistance is better characterized as “reactance” to eliminate its negative connotations

19. METHODS FOR EVOKING CHANGE TALK Ask non-directive, open-ended questions about ambivalence, change, motivation) Ask client to elaborate on comments (don’t “move on” too quickly) Ask clients to comment about the possible “extreme” consequences of their presenting issue Look back on, and explore, times when the problem was not present Look ahead to the client’s hopes for the future Explore the client’s ultimate goals and values

20. COMMON HAZARDS IN MOTIVATIONAL INTERVIEWING Underestimating the client’s ambivalence - it may persist long after change begins Prescribing a change plan that is too ambitious, too fast-faced, and not collaborative Providing too little guidance (A balance between #2 and #3 is desirable; jointly working out a “menu of alternatives” is a good strategy)

21. Trauma Informed Practice

22. In Your Work … Think about the people you work with, what are some of the traumas they have experienced? How do you think these experiences have impacted them in their day to day lives?

23. TRAUMA-BASED INTERVENTION Helps clents to: Learn skills to master the stress brought on by traumatic memories Master their reactions to things that may remind them of trauma Be abe to approach increasingly detailed distressing trauma-related reminders and memories Reprocessing of unhelpful thoughts

24. STRATEGY #1: PRIORITIZE SAFETY Early and ongoing validation of safety concerns Bring to awareness unsafe or potentially unsafe situations Explore impact of diminished safety Provide enhanced safety-seeking skills Safety plan should be age-appropriate, concrete, detailed, and rehearsed; with practice at home, rewards for following the plan, clear consequences for non-compliance Identify safe places, people, and settings

25. STRATEGY #2: ENHANCE ENGAGEMENT Engage helpful others such as caregivers, faith community, extended family, school Select several key others for the client to seek out to provide support and safety

26. STRATEGY #3: REAL DANGER VS. TRAUMA REMINDER The Trauma Narrative Desensitizes the client to memories of past trauma experiences Encourages reprocessing of maladaptive cognitions related to past Traumas Contextualizes past traumas into one’s entire life experience Describing trauma within the safety of the professional relationship allows youth to engage in perspective taking, cognitive processing, and contextualization

27. STRATEGY #4: PROVIDING ADVOCACY Focuses on skill building and empowerment, and perhaps the case manager’s active intervention, so that the client can learn how to gain access to other services.

28. CRISIS AND CONFLICT MANAGEMENT

29. THE NATURE OF CRISIS A crisis is the perception or experience of an event as an intolerable difficulty A crisis often results when people face a serious stressor with which they have no prior experience. The event may be: Biological (such as the experience of an illness) Psychological (an important relationship ending) Social (the closing of a town’s major industrial plant)

30. STAGES OF A CRISIS A sharp and sudden increase in the person’s level of tension The person tries but fails to cope with the stress, which further increases tension and contributes to the sense of being overwhelmed The crisis resolves, either negatively (with an unhealthy solution) or positively (with successful management of the crisis and perhaps an enhanced sense of competence)

31. TYPES OF CRISES Developmental - events in the normal flow of life create changes that produce extreme responses (the birth of a child, college graduation, a midlife career change, retirement) Situational - extraordinary events that a person has no way of forecasting or controlling (physical injuries, sexual assault, loss of a job, the death of a loved one) Existential - escalating inner conflicts related to issues of purpose in life (remorse over past life choices, a loss of meaning, a questioning of basic values)

32. THE EXPERIENCE OF STRESS Harm Threat Challenge Primary initial coping strategies include emotional numbing and denial

33. CRISIS OUTCOMES The growth pattern - the client recovers from the event and then develops new skills and strengths The equilibrium pattern - the client returns to the pre-crisis level of functioning The frozen pattern - the client does not improve, but makes adjustments that involve harmful strategies (such as substance abuse) that keep him or her in a troubled state

34. PSYCHOLOGICAL COPING Problem-focused coping (confrontation and problem solving) changes the stressful situation. This method is appropriate when we view the situation as controllable by action. In emotion-focused coping (distancing, avoidance, and reappraisal of the threat) the external situation does not change, but our behavior or attitudes change with respect to it

35. STAGES OF CRISIS INTERVENTION Rapidly establish a constructive relationship Encourage the client’s expression of feelings Rapid (and incomplete) assessment focuses on precipitating factors, existing capacities for adaptive functioning, and potential and actual supports Restore cognitive functioning Plan and implement interventions Termination and follow-up

36. ASSESSMENT QUESTIONS What contributing factors can the client identify relative to the onset of the crisis? What is the current quality of the client’s affective, cognitive, and behavioral functioning? Which areas are most adversely affected? Is the client self-destructive? Does the client require immediate medical or psychiatric attention? How does the client’s current functioning compare with pre-crisis functioning?

37. Assessment Questions (Cont.) Has there been significant trauma, illness, or pathology in the client’s past? What are the client’s strengths? Areas of stability? What are the client’s alternatives for managing the distress? What are the client’s current and potential support systems? Are there financial, social, or personal impediments to the client’s progress?

38. CRISIS INTERVENTION TASKS Make a positive connection with the client Act with a realistic view of the client's strengths, limitations, and “fluctuating competence” Maintain appropriate boundaries Model healthy behavior to facilitate the client’s movement from dependency to self-efficacy Alter the client’s physical environment as needed

39. Intervention Tasks (Cont.) Adjust support to maximize the client’s capacity for self-directed behavior Help the client’s significant others cope with the situation Appreciate the effects of social factors on the client’s sense of competence Appreciate the client's conscious and unconscious motives for behavior

40. SUICIDE Talking about suicide is scary, but it is a reality for those of us in human services. We often have misconceptions about talking about suicide with our clients. As case managers, you have the ability to prevent suicide by being aware of warningsigns and knowing how to intervene.

41. WARNING SIGNS: IS PATH WARM Ideation Substance abuse Purposelessness Anxiety Trapped Hopelessness Withdrawal Anger Recklessness Mood changes

42. MANAGING YOUR PROFESSIONAL RELATIONSHIPS: BOUNDARIES

43. BOUNDARIES These are defines as the assumed, often unspoken rules we internalize about the physical and emotional limits of our relationships with others They protect our privacy Through boundaries we organize our social worlds and communicate our positions within them We differentially construct boundaries to facilitate our desire to be close to, or separate from, others Each person’s boundaries are unique; covertly communicated to suit our assumptions and intentions about relationships Boundaries may change over time

44. FIVE ASPECTS OF BOUNDARIES Contact Time How much time is appropriate to spend in the company of the client? Will this vary depending on whether that time is spent face to face or on the phone? On the time of day or day of the week? The purpose of the contact? Types of Information to be Shared What is the appropriate range of topics to discuss with the client? Besides topics directly related to the problem area, what about social topics? What about politics, religion, and sex? How much depth can I be expected to provide about these topics?

45. Five Aspects of Boundaries (Cont.) Physical Closeness What are our expectations about personal space when in in each other’s company? How closely will we sit? Can he touch me? What range of non-verbal communications is appropriate? Territory To which of my environmental spaces does the client have access? From which spaces is he or she restricted? Can we only meet at the agency? What about the client’s home, or some community settings? Emotional Space To what extent am I willing to share my feelings about sensitive topics with the client? About what topics will we be expected to share feelings?

46. BENEFITS TO CLIENTS OF CLEAR BOUNDARIES A predictable interpersonal environment in which the client feels respected and safe A sense of individuality from having control of boundaries A basis from which to determine whether and when the social worker can cross certain boundaries. Boundary crossing implies an appropriate effort to adjust a boundary toward greater intimacy, while a boundary violation is an inappropriate entry into a client’s privacy.

47. BENEFITS TO THE CASD MANAGEROF CLEAR BOUNDARIES Role clarity regarding the range and limits of the worker’s activities A basis from which to make decisions about how and when to cross physical or psychological boundaries A means of preventing burnout by avoiding role overload Physical safety, when territorial boundaries are maintained

48. WARNING SIGNS OF POSSIBLEBOUNDARY VIOLATIONS Dual relationships, where the practitioner interacts with the client or the client’s significant others in more than one role Any exceptional behavior with a client (doing too much, protecting too much, identifying too much, having extended-length or more frequent meetings than is typical) Intrusion into the client’s territory (physical or geographic) The case manager’s self-disclosure Socializing with clients Accepting or giving gifts

49. FACTORS TO CONSIDER WHEN ASSESSINGONE’S OWN BOUNDARY CONDUCT The functioning level of the client (ability to use good judgment) The client’s history in relationships (patterns of behavior and his or her ability to manage conflicts or differences of opinion) The history and dynamics of this particular relationship (what patterns of interaction have been established, and whether a boundary-crossing activity is likely to be growth enhancing or a setback for the client) Cultural norms of both the worker and client

50. STRATEGIES FOR MANAGING BOUNDARIES Set clear boundaries with clients at the beginning Clarify boundaries with the client over time, as they will change Consider the preservation of the client’s privacy to be a major guiding value Be aware of your own emotional and physical needs as much as possible