CASE MANAGEMENT: EFFECTIVELY WORKING WITH CLIENTS

Nonprofit Learning PointMarch 19, 2014

AGENDA

Introductions / Overview

Case Management

Engagement

Motivational Interviewing

Crisis Intervention

Trauma-Informed care

Professional Boundaries

Self-Care

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?

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.

CASE MANAGEMENT

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

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

CM Activities (Cont.)

Environmental Interventions (cont.)

Advocacy Social actionRepresentation of client interestsPromotion of empowerment

Resource Development (including agency policy formulation)

Evaluation (of all services provided

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

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

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

MOTIVATIONAL INTERVIEWING

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?”

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

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

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)

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

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

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

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)

Trauma Informed Practice

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?

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

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

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

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

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.

CRISIS AND CONFLICT MANAGEMENT

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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)

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)

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)

THE EXPERIENCE OF STRESS

Harm

Threat

Challenge

Primary initial coping strategies include

emotional numbing and denial

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

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

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

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?

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?

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

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

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 warning signs and knowing how to

intervene.

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WARNING SIGNS: IS PATH WARM

Ideation

Substance abuse

Purposelessness

Anxiety

Trapped

Hopelessness

Withdrawal

Anger

Recklessness

Mood changes

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MANAGING YOUR PROFESSIONAL RELATIONSHIPS:

BOUNDARIES

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BOUNDARIES

These are defines as the assumed, often unspoken rules weinternalize about the physical and emotional limits of ourrelationships with others

They protect our privacy

Through boundaries we organize our social worlds andcommunicate our positions within them

We differentially construct boundaries to facilitate our desire tobe close to, or separate from, others

Each person’s boundaries are unique; covertly communicatedto suit our assumptions and intentions about relationships

Boundaries may change over time

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?

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?

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.

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

WARNING SIGNS OF POSSIBLEBOUNDARY VIOLATIONS

Dual relationships, where the practitioner interacts with theclient or the client’s significant others in more than one role

Any exceptional behavior with a client (doing too much, protectingtoo much, identifying too much, having extended-length or morefrequent 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

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

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

Managing Boundaries (Cont.)

Secure the client’s informed consent for all service activities

Understand the client’s cultural and community standards of

behavior

Use peer consolation and formal supervision routinely

Refer to codes of ethics when applicable

SELF CARE

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SELF-AWARENESS

Self-awareness is a core element in the responsible management of one’s self as a person and as a professional. It involves benign self-observation of physical and psychological experiences to the extent possible without distortion or avoidance.

The case manager can also be open to relevant feedback from others.

 

Common Self-Awareness Issues

Knowing what we can and cannot do

The tendency to demand too much of ourselves

The need to maintain realistic expectations of clients and agencies (the pace of change may be slow for both)

The understandable efforts of new staff to impress co-workers

The willingness to ask for help from supervisors and colleagues (and thus admit to limitations)

The extent to which we look to clients for personal satisfaction

BALANCE

Balance is defined as a positive connection and relationship with

ourselves, others, and our lifestyles that serves as an antidote to

professional stress. It is essential in enabling us to tend our core

needs, including those of the body, mind, and spirit.

 

PRACTITIONER SELF CARE

Case managers have the right, and deserve, to share with

themselves the same time, care, and tenderness they extend to

clients, family, and friends.

For some, the idea of self-care, although rationally sound, can

stimulate anxiety about the work and effort involved. It might

even seem threatening to address one’s vulnerabilities.

 

GOOD PRACTITIONER CARE:AGENCY STRATEGIES

Policies allow the agency to be responsive to client and

worker needs

Clarity of job descriptions, worker tasks

A striving to promote variety in work loads

Staff development opportunities

Facilitation of formal and informal support systems

Regular, scheduled supervision (individually or group)

A “shallow hierarchy” (functionally if not officially)

Staff participation in decision making

Valuing staff commitment vs. simple compliance

Differential and varied rewards for good work

BURNOUT

Defined as emotional and physical exhaustion brought about by work conditions

Possible reactions:

Advocating for changes

Finding a comfortable niche

Withdrawal

Outcomes:

Less energy to invest in others (clients, coworkers)

Responding to clients in detached ways

A reduced sense of accomplishment in one’s work

A CASE MANAGER’S SELF-CARE CHECKLIST

Recognize the Hazards of Practice

Accept the universality of the stresses you experience in practice

Invite friends and family to point out when you become too “clinical”

in your everyday life

Refuse to believe either your most idealizing or most devaluing clients

Pursue unrelated interests in your personal life

Be Aware of the Rewards of Direct Practice

Let your style of practice capitalize on your natural helping

characteristics

Focus on those occasional but exciting “life-changing” practice

experiences in which you had the good fortune to participate

Attend to you ongoing professional growth

Case management won’t make you rich, but it is a fascinating

way to make a living.

Nurture Relationships Inside and Outside the Office

Create opportunities for contact with supportive other practitioners

Make sure you get good supervisory support

Spend time every day with the people at the office who make you feel comfortable

Break up your workday with short contacts with friends and family

Set Boundaries

Define your relationships with colleagues with care. Don’t become obstacles to each other or expect too much in the way of help

Establish an agency identity apart from your role as a practitioner

Get your paperwork done right away! It won’t be any easier tomorrow. Actually it will be more difficult, because you will begin to forget details.

Create a Facilitative Work Environment

Enhance your work environment with comfortable furniture, pictures, posters, decorations, exotic coffees, incense, your favorite music, etc.

Cultivate a Sense of Mission

Identify a mission or purpose that pertains to your practice career

Think often about the reasons you became a case manager, and perhaps how your direction has evolved

Develop a sense of connection with the practitioners who came before you. Learn what they did and how they contributed to where you are today