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Social Work with Difficult Cases and Vulnerable Populations

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1 Social Work with Difficult Cases and Vulnerable Populations

2 What is a difficult case?
“When we call a client difficult, what we really mean is that we, the therapists, are having difficulty working with him/her.” (Wessler) This can mean two things: Something about the client presents new challenges for us, or the client triggers some of the therapist’s difficult feelings and issues. Difficult clients tend to leave a therapist feeling either confused or a variety of negative emotions. The latter involves two subtypes: the first comes from feelings the client elicits in the therapist, and the second comes from the therapist’s own issues.

3 What is a difficult case?
“Difficult patients are those who make us feel frustrated, uncomfortable, or ineffective ” (Duxbury) Difficult patients present some type of threat: They can reject us or harm us.  (Duxbury) Difficult patients are those whose disorders don’t respond to treatment. (Pollack)  Difficult families are those that don’t allow separation and differentiation. (Bergman)

4 Difficult cases are characterized by:
1.      multiple treatment failures 2.      high risk of suicide 3.      high risk of violence 4.      high risk of abuse 5.      high risk of legal action

5 We may define difficult people as those who lead us to do things we don’t want to do: We may define difficult people as those who lead us to do things we don’t want to do: 1.      react in ways we are not happy with 2.      do our jobs ineffectively 3.      feel guilty, anxious, upset, frustrated, inferior, defeated, etc. 4.      do their share of the work

6 Difficulty is about unmet needs.
The behaviors that make it difficult for us to work with clients result from our failure to meet their needs. When needs are not met, patients react by demonstrating:

7 Patient reactions 1. withdrawal – refusing to interact
2.   passivity – failure to take action 3.   manipulation – use of devious or dishonest means 4.   aggression – expression of anger with an implication of violence 5.   violence – physical act that is intended to cause damage to self, others, or property

8 Staff Skill Deficiencies
 1.  Failure to greet patients, introduce themselves, and explain procedures. 2.   Failure to elicit important information such as major worries and expectations. 3.   Acceptance of imprecise information. 4.   Failure to establish mutual understanding. 5.   Neglect of nonverbal cues provided by the patient. 6.   Failure to encourage or to adequately respond to questions.

9 Staff Skill Deficiencies
7. Avoidance of information about personal, family, and social situations. 8.  Failure to elicit information about the patient’s perceptions of the problem. 9.  A directive style that interferes with the patient’s telling of their story. 10. Focusing too quickly. 11. Failure to provide adequate information. 12. Failure to provide adequate reassurance.

10 Twelve types of difficult clients
1.      intimidating clients 2.      critical clients 3.      rageful clients 4.      threatening clients 5.      autonomous clients 6.      acting-out clients

11 Twelve types of difficult clients
7.   wealthy, influential clients 8.   angry victim with cultural or gender differences 9.   uncooperative clients 10.  passive-aggressive clients 11.  mistrustful clients 12.  unempathic clients All of these tend to be dominant and hostile. They can also be categorized as active or passive. The last four are passive.

12 Poor responders to CT 1. Severity (Beck Depression Inventory > 30).
2. Duration of current episode > 6 months. 3. Inadequate response to previous treatment. 4. Previous episodes > 2. 5. Associated psychopathology. (Axis II features) 6. Overall impairment as estimated by clinician as moderate or severe. 7. Poor estimated tolerance for life stress. Some clients do not respond well to treatment. When clients scored more the four items on A Global Severity/Chronicity Index (Hollon quoted in Fennell & Teasdale, 1982), they were unlikely to respond to cognitive therapy.

13 Indicators of Axis II features.
1. Life-long nature of a problem. 2. Persistent non-compliance with treatment. 3. Initial improvement comes to a plateau. 4. Patient seems unaware of the effect their behavior has upon others. 5. Therapist suspects the patient of lacking motivation to change. 6. Problems are reported as seeming natural to the patient—”That's the way I am”. On the other hand, there is considerable overlap in symptoms of Axis I vs Axis II disorders, so diagnosis of Axis II disorders in the presence of Axis I disorders may result in inappropriate labeling.

14 Rigid negative schemas
Conditional schemas – e.g. “Unless I am loved, I am worthless.” Unconditional schemas – e.g. “I am unloved.” Beck and Freeman see the schema as the basic unit of personality. Personality traits such as dependency or autonomy are reinterpreted as functions of hierarchically organized, aggregations of schemas whose activation triggers a chain of events culminating in overt behavioral patterns, termed 'strategies'. Schemas result from person-in-environment processes. Beck and Freeman suggest that rather than being purely derived from experience in childhood, strategies have an evolutionary origin and can be seen to have had survival value in previous eras but may not now fit well with current cultural norms. These consistent behavioral patterns or strategies are detectable in infants but can be modified or reinforced and accentuated through the responses of the environment, particularly that of parental figures in early development. Schemas or beliefs arise as a result of an interaction between innate programmed patterns of behavior and environmental responses. Schemas then control the processing of information from stimulus selection through interpretation and representation to overt action. They also suggest that there are separate systems of schemas for memory, cognition, affect, motivation, action, and control.

15 What makes a case difficult?
diagnostic dilemma poor prognosis multiple problems lack of interagency coordination involuntary participation lack of progress malingering and deception

16 What makes a case difficult?
imminent danger cultural competency gaps conflicting ethical principles eligibility limitations limited resources unacceptable client expectations 

17 Are there natural categories of difficult cases?

18 Natural categories 1. Challenges to the professional’s skill
2.      Challenges to the professional’s personality 3.      Unmatched expectations 4.      System issues such as eligibility and coordination problems 5.      Physically dangerous clients 6.      Legally dangerous clients 7.      Socially dangerous clients

19 How should we respond to difficult cases?

20 Responses to Difficult Cases
  1.      Identify the challenge 2.      Assess expectations 3.      Assess skill level 4.      Assess personality strength 5.      Assess dangers 6.      Evaluate danger-mitigating options 7.      Decide whether to keep or to refer the client If the social worker keeps the client, it is important to identify his or her own personality style and recognize how it fits with the personality of the client so the social worker can avoid personalizing what the client says and does. At the same time, it is imperative that workers recognize their limitations and refer clients appropriately.

21 Six categories of intervention
A.     Authoritative categories          i.      Prescriptive interventions         ii.      Informative interventions        iii.      Confrontational interventions B.     Facilitative categories          i.      Cathartic interventions         ii.      Catalytic interventions iii Supportive interventions John Heron (referenced in Duxbury) identifies six categories of intervention. The worker’s responsibility is to use the intervention appropriate to the circumstance.

22 What is the connection between difficult cases and vulnerable populations?
There may be no connection. On the other hand, there may be a connection between some of the characteristics that lead to cases being conceptualized as difficult and the characteristics that lead to them being conceptualized as vulnerable. For example, cases of people with chronic mental or physical illness are difficult because of the chronic nature of the problems, and the people with the problems are vulnerable because of the same reason.

23 What are some vulnerable populations?
a.      Impoverished people b.      People who are financially dependent c.      People with physical illness d.      People with mental illness e.      People with developmental delays f.        Victims of family violence g.      Elderly people h.      Migrant workers i.        Homeless people j.        Infants with medical problems k.      Children awaiting adoption l.        Children in foster care m.    People with substance abuse problems n.      Children who have run away o.      Children who have been abused p.      Families in violent neighborhoods q.      Members of ethnic minorities r.       People who are unemployed s Children who have lost a parent through death, divorce, or incarceration

24 What about those situations makes the people in them vulnerable?
Vulnerability may conveniently be thought of as risk, in the statistical sense. For example, a teenaged male of African ancestry living in the United States has a statistically higher risk of ending up in prison than a same aged male of European ancestry. Similarly, a woman living on the streets has a calculably higher risk of being assaulted than a woman living in her own home.

25 To what are vulnerable populations vulnerable?
They are vulnerable to a whole range of circumstances and illnesses that interfere with successful functioning. For example, despite the claim by people in the domestic violence shelter movement that domestic violence is no respecter of social class, those who live in poverty are more likely to experience family violence. Similarly, there is an increased risk of substance abuse among people living in poverty. Children of parents who have a mental illness are more likely to have a mental illness themselves. Members of some ethnic minorities are at increased risk of having untreated mental and physical illnesses, even after income and insurance status are accounted for. As we examine social work with difficult cases and vulnerable populations, I anticipate that we will see a pattern emerge and that as that pattern emerges, we will become better equipped to work with the most challenging clients who often are members of the most vulnerable populations.

26 References Bergman, J.S. (1985). Fishing for barracuda, Pragmatics of brief systemic therapy. New York: Norton. Duncan, B.L., Hubble, M.A., & Miller, S.D. (1997). Psychotherapy with “impossible” cases: The efficient treatment of therapy veterans. New York: Norton Duxbury, J. (2000). Difficult Patients. Oxford: Butterworth-Heinemann. Pollack, M.H., Otto, M.W., & Rosenblum, J.F. (Eds.). (1996). Challenges in clinical practice: Pharmacologic and psychosocial strategies. New York: Guilford. Wessler, R., Sheenah, H., & Stern, J. (2001). Succeeding with difficult clients: Application of cognitive appraisal therapy . Sand Diego, CA: Academic Press Williams, Ruth M. (1994). Cognitive therapy for difficult patients--a review. International Review of Psychiatry, 6, 2/3, pp


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