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N A S W S P SNational Association of Social WorkersSpecialty Practice Sections©2004 National Association of Social Workers.All Rights Reserved.

IN THIS ISSUE

Rapid Assessment Instruments:Tools for the AccountableProfessional ........................ 1

From the Editor ........................ 2

ADHERE: A Practice Model forEnhancing Client Follow-through with RecommendedTreatments .......................... 3

Social History Updates .............. 7

The Mental Health SectionCommittee Welcomes MarkSmith .................................. 8

A Focus on Ethics ...................... 9

SPRING 2004

RAPID ASSESSMENT INSTRUMENTS:TOOLS FOR THE ACCOUNTABLE PROFESSIONAL

See Rapid Assessment Instruments, 1

Steven L. McMurtry, PhD and Susan J. Rose, PhD

In the current era of managed care, directcontact time with clients is often severelyconstrained, and practitioners face adifficult task in dividing the minutesavailable among such varied tasks asproblem identification, relationshipdevelopment, intervention, and guidingthe client toward termination. In addition,as funding sources’ requirements foraccountability and quality control in-crease, practitioners must also completeinitial assessments, monitor progress on anongoing basis, and evaluate outcomes.

Managed care methods often seem para-doxical for mental health professionals, inthat they limit client contact time—andthus measurement time—while mandatinggreater accountability that can be accom-plished only through improved measure-ment. Not surprisingly, considerabledemand has arisen for reliable and validmeasures that can help meet accountabilityrequirements, while maintaining a good fitwith the professional training, treatmentorientation, and time constraints ofpractitioners.

Fortunately, the number and range ofstandardized assessment scales availablefor use in practice and research haveexpanded rapidly in the past 10 to 15years. Brief measures, sometimes referredto as rapid assessment instruments orRAIs, are a particularly fast-growing

subset. RAIs are distinguished from othermeasures by their variety, ease of use,cross-disciplinary applicability, low cost,and, above all, brevity. Most include fewerthan 50 items, some have fewer than 10,and all can be completed by most clients ina relatively brief time—often as little asone to five minutes. This allows standard-ized measurement to be a brief part ratherthan a principal component of clientcontacts.

Unfortunately, many professionals areunaware of these instruments or theirbreadth and diversity. Others know aboutRAIs, but employ them only sparingly dueto lack of information about the types ofmeasures available; how to identify andselect them; how to determine which areconsidered best; how to obtain the RAIsthey wish to try; or because they believe,often incorrectly, that the measures canonly be applied by licensed psychologistsspecializing in psychometric testing. Ourgoal is to provide an overview of RAIs,how they can be used, how they can belocated and evaluated, and how to makethem a tool for enhancing practice ratherthan simply another layer of paperwork.

Types of RAIsWe define RAIs as empirically testedmeasures with known psychometric

2 Spring 2004 • Mental Health SectionConnection

SECTION COMMITTEE

CHAIRBarbara A. Conniff, ACSW

Pittsburgh, [email protected]

EDITORLana Sue I. Ka’opua, PhD, ACSW

Kaneohe, [email protected]

Gail Johnson, MSW, LCSWMilwaukee, WI

Gwendolyn Strong Scott, ACSW,LMSW-ACP, BCD

Bellaire, [email protected]

[email protected]

Mark Smith, ACSW, LISWMarshalltown, IA

[email protected]

NASW SPS MANAGERNancy Bateman, LCSW-C [email protected]

SPS SENIOR MARKETINGASSOCIATE

Yvette [email protected]

SPS SENIOR POLICY ASSOCIATELa Voyce Brice Reid, LCSW

[email protected]

SPS SENIOR ADMINISTRATIVEASSISTANT

Antoniese [email protected]

THE NEWSLETTER OF THE NASW SECTIONON MENTAL HEALTH

MentalHealth

SectionConnectionFromthe Editor

See Editor, Page 16

FOCUS ON PRACTICE IN 2004The strength of social work as a profession resides in its capacity toprovide competent and ethical interventions in sensitive humansituations that frequently occur in complex social environments.Enhancing professional capacity to meet the challenges in theevolving landscape of mental health services remains the primarypurpose of the Mental Health Specialty Practice Section. In 2004 theMental Health Section Connection aims to address this purposethrough the presentation of practice-relevant knowledge.

Focus on Enhancing Practice-RelevantKnowledgeAssessment and intervention with adult consumers of mental healthservices is the focus of this issue of the Mental Health SectionConnection. Featured are up-to-date descriptions of important anduseful practice technology and models. The contents of this issueinclude:

• Rapid Assessment Instruments [RAI]: Tools for the AccountableProfessional In this substantive overview of RAI, Drs. Steven L.McMurtry and Susan J. Rose, faculty at the Helen Bader Schoolof Social Welfare at University of Wisconsin-Milwaukee,summarize types of instruments, their differential use in clinicalpractice, and resources for obtaining RAI. This groundbreakingcontent is adapted from the authors’ forthcoming book on RAI.

• ADHERE: A Practice Model for Enhancing Client Follow-Through with Recommended Treatments This article describes aclient-centered and ecologically oriented model for addressingtreatment adherence, an enduring therapeutic concern of socialworkers across all practice settings. The authors, Lana SueKa‘opua, PhD, ACSW, LSW, of the Cancer Research Center atUniversity of Hawai‘i, and Brian Giddens, ACSW, LISW, of theUniversity of Washington Medical Center, developed thisconceptual model through a national collaboration that in-cluded practitioners, educators, and researchers associated withNASW’s “HIV/AIDS Spectrum: Mental Health Training andEducation of Social Workers Project.”

• Social History Updates describes the consumer-friendly, practitio-ner-friendly system developed by Mark Smith, ACSW, LISW,associate director of Center Associates, a community mental

Mental Health SectionConnection • Spring 2004 3

See Model, Page 4

ADHERE: A PRACTICE MODEL FOR ENHANCING CLIENTFOLLOW-THROUGH WITH RECOMMENDED TREATMENTS

Helping clients adhere to a treatment regimenis a frequently expressed concern of socialworkers in the mental health and healthpractice specialties. To address this concern,ADHERE, a client-centered and ecologically-oriented practice model, was developed bythe NASW HIV/AIDS Spectrum: MentalHealth Training and Education of SocialWorkers Project (2003). ADHERE drawsfrom research in HIV and other chronicillnesses and specifically focuses on interven-tion with psychological, sociocultural, andenvironmental factors associated withadherence, or dedicated follow through witha prescribed regimen (Becker, 1990; DiMatteoand DiNicola, 1982; Ka‘opua & Mueller,2004; Linsk & Bonk, 1999; Prochaska &DiClemente 1983). Although initially concep-tualized to facilitate support for medicationadherence to Highly Active AntiretroviralTherapy (HAART), ADHERE may offerhelpful considerations to social workers andother healthcare providers involved incounseling and therapy, home health care,and mental health/health case management topersons living with a chronic illness anddesiring to follow through with exercise,dietary, and/or routine clinic visits andscreenings.

Living with a chronic illness is described as“unending work and care” (Corbin &Strauss, 1988) and adherence to a prescribedregimen is just one of many challenges facingthe client and his or her significant others.For persons living with a chronic illness, atreatment regimen is often open-ended, or ofindefinite duration. Adherence to such atreatment regimen is more difficult becausethe latter often competes with other tasks ofdaily living, including those related to illness,symptom, and pain management, occupa-tional and family responsibilities, and bio-graphical work, or coping with changingperceptions of self in relation to the world

(Charmaz, 1991;Corbin & Strauss,1988; Ka‘opua,2001). In the dailylife of clients andfamilies, adherenceoften involvesincorporation ofnew behaviors intoroutines developedover the course oftime, as well as modification of roles andbehaviors that may be deeply ingrained andculturally patterned. Given the multitude andmagnitude of adherence-related challenges, itis understandable that success in followingprescribed treatment ranges from 20-80%with an average adherence rate of 50%(Gerber & Nehemkis, 1986; Haynes, 1976).Although imperfect adherence is somewhatnormative, certain medical conditions likeHIV require higher levels of adherence toobtain therapeutic results (Ka‘opua &Mueller, 2004; Linsk & Bonk, 1999).

Intervention research indicates that adherenceintent and behavior are associated withknowledge relevant to health recommenda-tions, attitudes about the disease and itstreatment, and sociocultural norms transmit-ted through the family and other groups withwhich individuals identify (DiMatteo &DiNicola, 1982). However, intent to adhere isnot the only factor in following through witha recommended regimen. In the socialenvironment, adherence behavior is power-fully influenced by factors that either enableor disable follow through behavior. Factorsinfluencing adherence include: the extent andnature of social support from natural andprofessional networks, accessibility to healthresources, and the availability of culturallyacceptable, linguistically appropriate care

Lana Sue Ka‘opua, Ph.D., ACSW, and Brian Giddens, ACSW

A: Assess knowledge & readinessD: Dialogue about beliefs & attitudes.H: Holistic Approach is important.E: Empower client.R: Reinforce strategies.E: Evaluate progress.


Model, from Page 3

(DiMatteo & DiNicola, 1982; Linsk & Bonk,2000). The ADHERE model identifies sixconsiderations for practitioners assistingclients in treatment adherence at its intersec-tion with mental health and health condi-tions.

A: Assess client knowledge and readiness fortreatment initiation. Assessment optimallyresides in a relational environment of col-laboration involving client, significant others,social worker, and other members of thehealthcare team. Because the diagnosis ofHIV and other chronic illnesses may carrysocial stigma and because imperfect adher-ence often has negative connotations, it isimportant for the social worker to communi-cate acceptance for client beliefs, decision-making processes, and treatment choices.Assessment involves exploration of client andfamily understanding of the recommendedregimen and is facilitated through the use ofopen-ended, non-confrontational questions,such as:

• What have you heard about this treat-ment?

• What do you believe are your options?What do those closest to you believe arethe options?

• Do you believe that this treatment is do-able for you?

• What do you think may keep you fromfollowing treatment recommendations?

In assessing knowledge and readiness, it isimportant for the practitioner to elicit currentperceptions of health status, beliefs abouttreatment benefits and disadvantages, and toprovide verbal and written information thatis congruent with client’s knowledge andunderstanding. Attention to the use oflinguistically and culturally appropriate termsand meanings, as well as explanations thatconsider client’s literacy level are critical inensuring mutual understanding of regimenadherence and challenges.

D: Dialogue periodically about health beliefs& illness-related attitudes. Unanticipatedbarriers to follow-through may emerge overtime. Therefore, on-going discussion isnecessary to support adherence to a treat-ment regimen, especially when recommenda-tions must be followed for an indefiniteduration. Communication of empathy andunconditional positive regard for the clientserves as the basis for discussing difficultieswith adherence and lays an essential founda-tion for future discussion of treatmentadherence. Challenges to optimal adherenceand non-adherent behavior are relativelycommon and it may be helpful for the socialworker to normalize adherence-relateddifficulties, purposefully assuring the clientthat the healthcare team does not equateadherence difficulties with being an uncoop-erative or “bad” client. Consequences of non-adherent behavior may then be discussedwithin the context of the client’s health goalsand beliefs about what she or he considers tobe an acceptable quality of life.

Carefully listening to the client’s attitudesabout living with a chronic illness is funda-mental to dialogue and necessarily includes:

• Attitudes about diagnosis, treatment, andquality of life.

• Past and current ways of coping withillness and other adverse life situations.

• Positive and negative experiences withproviders and the healthcare system.

Anticipation of evolving client needs andpotential strategies for addressing these needsmay be linked to environmental barriers andare optimally addressed as part of theongoing collaborative alliance between theclient and social worker. Family membersrelated by blood and/or choice, as identifiedby the client, may be important to include insuch discussions, especially when the client isfrom a collectivist oriented culture and valuesinterdependent family relationships.


See Model, Page 6

H: Holistic approach is important. Based onthe initial assessment and dialogue, thepractitioner will have collected significantinformation about client strengths and needs.The practitioner will also have a sense ofwhether the client’s orientation is primarilyindividualistic or collectivist; and this informsdecisions about whom to include in thetreatment planning process. Elicitation of theclient’s understanding of the illness is essen-tial and optimally includes the client’s healthbeliefs, cultural practices, environmentalbarriers, and preferred learning and copingstyles. Because a client may present withmore than a single mental health concern, thesocial worker needs to take a holistic ap-proach in addressing issues of drug use,physical health concerns, and resource needs.

There are several environmental barriers toengaging and sustaining the client’s participa-tion in mental health treatment. The clientwho abuses drugs, often as a self-treatmentfor mental illness, can find that the drugsexacerbate the symptoms of mental illnessand may have a diminished capacity tomanage a treatment plan. Homelessness canmake a client vulnerable, and requiresexpending countless hours and physical andpsychic energy planning for a place to sleep.Being homeless may force a client to movefrom one area to another and can prevent atherapist from being able to reach a clientwhen needed. Financial status is also abarrier. Community mental health used to bea guaranteed resource for mentally ill personswho had no funds; however, this criticalsafety net is rapidly becoming inadequate asrestrictions increase and functionally, preventaccess to unfunded patients.

Environmental barriers also encompass lesstangible issues, such as culture and relation-ship/familial history. With which culturemight a client identify? In some cases, theclient may freely disclose this. In othersituations, due to shame or perceived bias,the client may not speak of their culture buttheir behaviors may still be reflective of

cultural influences. Cultural issues can bebest understood by asking the client abouttheir health beliefs, and their understandingof their health and/or mental health situation.It is the practitioner’s role to listen, and to tryto understand how the client’s culture canpositively and negatively influence adherence.For truly holistic care, the social worker mayneed to have available resources for otherservices and needs, and may strengthen theirtreatment plan by collaborating not only withthe patient’s perceived support systems, butwith other professionals and communityprograms.

E: Empower client to implement the actionplan. Respect for the client’s choice isfundamental and the social worker optimallyempowers the client to implement an actionplan, regardless of whether a client decides toinitiate treatments recommended by thehealthcare team or to follow another alterna-tive. The client who chooses to initiate arecommended regimen, may find it helpful toidentify cues, reminders, and daily activitiesthat serve as environmental reminders. Forexample, one young mother is cued to takeher medication as soon as her children leavefor school. Equally important is the develop-ment of an action plan considering unex-pected events and/or changes in routines thatpotentially compromise adherence efforts. Inthe context of adherence to complex, HIV-related medications, other issues such asstorage of medications need to be identified.Socially stigmatized medical conditions likeHIV require attention to how the need forprivacy affects adherence to a regimen. Opendiscussion of client successes and concerns ispotentially empowering and may be facili-tated by dialogue prompted by questionssuch as:

• How are you coping with this plan?

• Help me to understand how this plan isworking for you—what do you think isgoing well? What needs some attention?


Model, from Page 5

• Give me an example of when this plan isdifficult for you to follow. In the lastthree days how many doses of medica-tion did you miss? On the average, howmany doses are you able to take, asprescribed? Which medications/dosescause the most difficulty for you?

• How satisfied are you with your currentregimen?

R: Reinforce strategies. Increasingly empha-sized is the importance of appropriate andongoing client education to ensure that theindividual and members of his or her supportsystem understand the multiple tasks oftreatment adherence. Review of the treat-ment plan and reinforcement of what isworking for the client are both essentialcomponents of this type of education. Forthe mental health practitioner, reinforcingstrategies helps the client to focus on thedesired outcome, and to relate the treatmentprocess to a tangible goal. Discussing“successes” when they happen (e.g. followingthrough with medications, keeping anappointment for a psychiatric consultation,working with a collaborating agency tosecure a resource) can be appropriatelyintegrated into the therapeutic work. Inreviewing and reinforcing the client’s role inensuring adherence to a treatment plan, thesocial worker can also continually reassessthe worth of the plan with the client. Regu-lar reassessment is key to noting changes inthe client’s situation that might make theinitial plan unworkable for the client. Giventhe challenging and even chaotic lives ofsome of our clients, the social worker mustbe prepared to adjust the plan accordingly,being flexible enough to recognize the impactof emerging barriers. It is important to notethat problems with adherence may be aclinical issue, or may reflect the inability orunwillingness of a client to engage in mentalhealth treatment. Unfortunately, many

clients with extensive cultural and/or environ-mental issues get pegged as being the prob-lem, when in fact there may be legitimatereasons why the client is unable to adhere toa treatment plan.

Evaluate progress and resources. What is thedifference between review and evaluation?Evaluation tends to look over time at thework one is doing with a client and/or family.It is also an overall review of methodologieschosen, interventions attempted, and whetherthe client goals were met. Review tends to bemore micro practice, scanning for changes inthe client’s status and needs, and makingadjustments along the way. The evaluationcomponent is macro-focused, taking aretrospective examination of the progressmade to date, and looking carefully at issuessuch as consistency in practitioner methodol-ogy, observing for overall improvements inclient functioning, and looking for patterns inclient behavior based on interventionsutilized. Clinicians, as well as administrators,benefit from this global view, as it allows forgreater chance of reflection and removes thepractitioner from becoming caught up in thesession-to-session struggles the client may bepresenting. Evaluation should also extend tothe broader array of resources the socialworker relies on when using a holisticapproach. Considerations include:

• Were the resources provided effective?

• Did the relationship between theprovider(s) and the client (system)facilitate or impede progress?

• How do emerging changes in the servicedelivery system impact the client (sys-tem)?

In summary, helping clients in the criticalhealth/mental health area of treatmentadherence requires strong therapeutic skills,as well as an understanding of how factors inthe client’s social environment impact upon


adherence behaviors. The person-in-environ-ment perspective of social work practiceoptimally informs assessment and interven-tion. From this perspective, family, commu-nity, and cultural factors are considered withattention to how these factors either facilitateor disable treatment adherence. A clearunderstanding and thoughtful integration ofecological factors into intervention optimally,promote communication between client, theclient system, the practitioner, and ultimately,the service delivery system. When this kind ofcommunication is ongoing, the risk of non-therapeutic adherence and its related frustra-tions are minimized. This perspective is not anew one, but reinforces the unique andcritical role of social work in mental healthtreatment.

ReferencesBecker, M. H. (1990). Theoretical models of adherence

and strategies for improving adherence. In S.A.Shumaker, E.B. Schron, & J. K. Ockene (Eds.), Thehandbook of health behavior change (pp. 5-43). NewYork: Springer.

Charmaz, K. (1991). Good days, bad days: The self inchronic illness and time. New Brunswick, NJ: RutgersUniversity.

Corbin, J. M. & Strauss, A. (1988). Unending work andcare. San Francisco: Jossey-Bass.

DiMatteo, M. R. & DiNicola, D. D. (1982). Achievingpatient compliance. The psychology of the medicalpractitioner’s role. New York: Pergamon.

Gerber, K. E. & Nehemkis, A. M. (1986). Compliance.The dilemma of the chronically ill. New York:Springer.

Haynes, R. B. (1976). A critical review of the determi-nants of patient compliance with therapeuticregimens. In D.L. Sackett & R. B. Haynes (Eds.),Compliance with therapeutic regimens, (pp.26-39).Baltimore: Johns Hopkins University.

Ka‘opua, L. S. (2001). Treatment adherence to anantiretroviral regime: The lived experience of NativeHawaiians and kokua. Pacific Health Dialogue,Journal of Community Health and Clinical Medicinefor the Pacific, 8, 290-298.

Ka‘opua, L. S. & Muller, C. W. (2004). Treatmentadherence among Native Hawaiians living with HIV.Social Work, 49, 55-64.

Linsk, N. L. & Bonk, N. (1999). Adherence to treatmentas social work challenges. In V. J. Lynch (Ed.) HIV/AIDS at year 2000 (pp. 211-227). Boston: Allyn &Bacon.

NASW HIV/AIDS Spectrum: Mental Health Training andEducation of Social Workers Project (2003). The roleof social work in medication treatment adherence.Washington, DC: author. (Available atwww.socialworkers.org/practice/hiv_aids/spectrum.asp)

Prochaska, J. O. & DiClemente, C. C. (1983). Stagesand processes of self-change of smoking: Toward anintegrative model of change. Journal of Consultingand Clinical Psychology, 51, 390-395.

Lana Ka‘opua, Ph.D., ACSW, LSW, is AssistantProfessor at the Cancer Research Center, University ofHawai‘i; e-mail: [email protected]. BrianGiddens, LICSW, ACSW is Associate Director of SocialWork at the University of Washington Medical Center.Both are advisory committee members of the NASWHIV/AIDS Spectrum: Mental Health Training andEducation of Social Workers Project.

The authors acknowledge Susan Hakailis, ACSW,Nathan Linsk, Ph.D., and Evelyn Tomaszewski, MSWfor their intellectual contribution to this practice article.

SOCIAL HISTORY UPDATESMark Smith, ACSW, LISW

Many social workers employed in the mentalhealth field provide brief mental healthservices. However, we also know that somemental health conditions are long term andthat, in the community mental health setting,social work services are often needed by the

client on an ongoing or intermittent basisover a period of years.

Often, state administrative rules requireannual social history updates for consumers

See History, Page 8


History, from Page 7

receiving services. This is usually an effort tokeep rapidly changing contact, patient care,and demographic information current, andserves as a basis for care managers to havereadily available information.

However, the gathering of this information isnot a billable service, is time consuming, andoften irritates clients who may feel theirtreating mental health professionals shouldbe familiar with this information throughwhat they (the clients) have conveyed.

I am a social worker who has providedmental health treatment to people in the samegeographic area for the past 17 years. Themanaged care and regulatory paperworkrequirements are often frustrating. Forexample, consider the following scenario: Aclient has discontinued ongoing services withme, continues with psychiatric services with acolleague, and then presents again for myservices. At that time, I discover he or she isdue for an annual social history update.

An annual social history update is importantand significant to best practices. Therefore, Isought to obtain a mechanism for completingthis responsibility, while keeping face-to-faceinteraction focused on therapeutic issues.

The mechanism I use is the survey question-naire below. A “flag” is placed in the com-puterized consumer record managementsystem to remind me when the update is due.The survey is given to the consumer at theappointment that corresponds with thereview date. After the consumer completesthe information, I review it with the con-sumer and dictate a summary of the informa-tion on a page in the record, titled, AnnualSocial History Update (see Page 9).

To summarize, this approach enables socialworkers to have updated social historyinformation available, keeps direct servicestime devoted to this need to a minimum, andfacilitates the gathering of information on aconsistent basis.

Mark Smith, ACSW, LISW, is associate director ofCenter Associates, in Iowa. He can be reached [email protected].

THE MENTAL SECTION COMMITTEE WELCOMES MARK SMITH

Mark Smith, ACSW, LISW, is associatedirector of Center Associates, a communitymental health center serving Marshall andHardin Counties in Iowa. He recently joinedthe mental health specialty practice sectioncommittee. Mark has been a member ofNASW and the Iowa Chapter since 1986.

A graduate of University of Iowa School ofSocial Work, Mark has worked in communitymental health since 1982. In 2000, he was

elected to the Iowa House of Representatives,and was re-elected in 2002. He serves asranking member of the Human ResourcesCommittee where legislation affectingcommunity mental health and the practice ofsocial work is addressed. In addition to theseduties, he maintains a mental health caseloadand teaches social policy and practice atUniversity of Iowa School of Social Work. Hecan be reached at [email protected]


I. Living arrangements:A. Please check any of the following changes that have occurred in the past year:

______ divorce ______ marriage ____ cohabitation ______ separation______ death of spouse ______ death of other family member______ new address ______________________________________________________________________________________________________________________ new telephone ______ name change______ birth of child ______ other:______________________________

B. Please explain any checked areas above: ___________________________________________________________________________________________________II. Education and Employment:

A. Have you received additional education in the past year? ______ Yes _____ NoB. If yes, please explain: _________________________________________________________________________________________________________________C. During the past year, have you taken new employment or had a job change? ______ Yes ______ NoD. If yes, please explain: _________________________________________________________________________________________________________________

III. Medical:A. My physicians, physician assistants, and advanced registered nurse practitioners are: ___________________________________________________________B. My medications are: __________________________________________________________________________________________________________________C. I am allergic to the following medications: ________________________________________________________________________________________________D. During the past year, I have had the following surgeries or health problems: ___________________________________________________________________E. During the past year, I have been hospitalized for the following reasons: _______________________________________________________________________

IV. Substance Use:A. I have used the following substances (check all that apply):

______ alcohol ____ tobacco ____ caffein ____ marijuana______ cocaine ____ methamphetamine ____ other: ______________________________________________________________

B. I have been in treatment for substance abuse during the past year: ______ Yes ______ NoC. Please explain: ______________________________________________________________________________________________________________________

V. During the past year, I experienced domestic violence or other abuse in my life: ________________ Yes ___ NoVI. Which of the following best fits your legal involvement:

______ A. No legal involvement ______ B. On mandatory outpatient status______ C. Involved with the criminal justice system ______ D. Involved with the civil justice system (lawsuit, divorce, or other action)

Thank you for completing this survey. Please give it to the mental health professional with whom you have an appointment.

The following information is used to update your record here at Center Associates. Annually, we ask you to take a few minutes and complete the followinginformation. Thank you!

Name: _________________________________________________________________________ Date: ___________________________________________________

SAMPLE ANNUAL REASSESSMENT AND SOCIAL HISTORY SURVEY

Gail Johnson, MSW, LCSW

WHO ENSURES OUR COMPETENCE IN USING RAIAND OTHER STANDARDIZED MEASURES?

A Focus onEthics

This is the first article in a new regularcolumn—A Focus on Ethics in Practice—ofthe Mental Health Section Connection. It isour goal to encourage discussion, and wehope that this column will become a vehicle

for the exchange of information aboutcurrent issues in ethical practice.

See Ethics, Page 10


Since both the Ka‘opua/Giddens and theMcMurtry/Rose articles address assessment, Iwas prompted to consider a related issuecurrently being worked on in the State ofWisconsin—namely, that of ensuring socialwork competence in the use of Rapid Assess-ment Instruments (RAI) and other standard-ized measures. Our work in Wisconsin leadsme to wonder how other states are consider-ing this critical ethical issue in social workpractice.

Currently Wisconsin’s licensure act requiresthat a licensed social worker submit evidencethat his or her academic training at thegraduate or postgraduate level included:descriptive statistics; reliability and measure-ment error; validity and meaning of testscores; normative interpretation of testscores; selection of appropriate tests; testadministration procedures; ethnic, racial,cultural, gender, and linguistic variables; and,finally, the testing of individuals with disabili-ties. He or she must also provide an affidavitfrom a professional who is qualified tosupervise psychometric testing, indicatingthat the individual licensee has acquiredsupervised experience and specific qualifica-tions for the responsible selection, adminis-tration, scoring, and interpretation of one ormore particular psychometric tests—includ-ing, if appropriate, use of the tests in particu-lar settings or for specific purposes.

The bottom line is that the ExaminingBoard’s approval is needed before a socialwork licensee can do any kind of psychomet-ric testing, including, for example, the BeckInventories. Members of the ExaminingBoard are working to come to an agreementwith the Psychology Board that would allowprofessionals other than psychologists to usestandardized tools like the Beck Inventoriesafter meeting the requirements that the test’spublisher sets for administering them. In theMcMurtry\Rose article, the statements thatrelate strongly to this issue are:

Training in the selection and use ofRAIs must then be a standard curricu-lum component in social work educa-tion, not only with respect to degreetraining but in continuing education aswell. It is also important to dispel thenotion that social workers lack the skillor professional qualifications to employsuch measures.

The NASW Code of Ethics, under Compe-tence (1.04) (a) and (b), clearly indicates ourresponsibilities in this matter. Especiallyrelevant is (a), which states, “That socialworkers should provide services and repre-sent themselves as competent only within theboundaries of their education, training,license, certification, consultation received,supervised experience, or other relevantprofessional experience.”

In Wisconsin’s Code of Conduct, in thedefinition of gross negligence, there isreference to not complying with an acceptedstandard of practice. That standard ofpractice in Wisconsin is the NASW Code ofEthics. It is my understanding that this is alsotrue in most other states. I would argue, then,that no need exists for such specific stateExamining Board review and approval, sincethe NASW Code of Ethics defines compe-tence and uses the same code for definingstandards of practice. From a practicalperspective, it also seems that state resourceswill be taxed further when most states, likeWisconsin, are facing serious financialproblems. I am also concerned about turningto another profession to define our compe-tence and practice. It seems to me that,historically, we have done this in mentalhealth, and not always with the best results.The other issue is for us to be sure thatschools of social work can assure the licens-ing boards and the public that social workershave the skills and professional qualificationsfor utilizing RAIs, because they have made itan integral component of the required

Ethics, from Page 9


properties (e.g., reliability and validity) thatare used to assess client problems, character-istics, attitudes, or behaviors, which can becompleted by most clients in 15 minutes orless. As with other standardized measures,RAIs come in three main types: self-adminis-tered forms, other-administered forms, andobserver-rating forms.

Self-administered RAIs, the most commontype, are completed by clients in paper andpencil form or on a computer. The latter isbecoming increasingly common for its abilityto expedite scoring. It can be done through astand-alone computer program or by direct-ing clients to a Web site where the form islocated. Well-known examples of self-administered RAIs include the Beck Depres-sion Inventory (BDI), Rosenberg Self-EsteemScale, and State-Trait Anxiety Inventory(STAI).

Other-administered forms usually consist ofsome type of interview schedule, often usedwith clients who have disabilities or readinglimitations, which are administered byclinicians, researchers, teachers, familymembers, nurses, or other helping profession-als. Many diagnostic inventories, such as the

Structured Clinical Interview for DSM-IV(SCID), take the form of client interviews,but because they typically require far longerthan 15 minutes to administer, these are notconsidered RAIs. Others, such as theMini-International Neuropsychiatric Inter-view (MINI), are interview schedules that canbe completed with most clients within asufficiently short time to qualify as RAIs.

Observer-rating forms are measures thatpractitioners, researchers, family members,teachers, hospital staff, or other onsitehelping professionals complete about aparticular client, based on their familiaritywith the individual or on knowledge gainedfrom observations. Examples include theBrief Psychiatric Rating Scale (BPRS), GlobalAssessment Scale (GAS), and the Mini-Mental State Examination (MMSE). Practi-tioner-rating measures that must be precededby a lengthy clinical interview cannot beproperly defined as RAIs.

Uses of RAIsRAIs can be used for a variety of purposes,including screening, readiness for treatment,formal diagnosis, non-diagnostic assessment,

See Rapid Assessment Instruments, Page 12

Rapid Assessment Instruments, from Page 1

curriculum. It is also important that schoolsof social work and NASW chapters thatprovide continuing education are certain toinclude offerings on this topic, as post-graduate education and training for socialworkers is crucial.

It would be helpful if we could have somediscussion on these two topics. Often, westruggle with issues like this without the fineexamples, historical perspectives, andthoughtful analyses that exist in othergeographical areas. Our profession is so

much stronger when we find ways to drawon each others’ experience. You can exchangeinformation via the Mental Health SpecialtyPractice Section “Online Forum,” atwww.socialworkers.org/sections

ReferenceNational Association of Social Workers. (2000). Code

of ethics. Washington, DC: NASW Press

Gail Johnson, MSW, LCSW is a member of the MentalHealth Specialty Practice Section committee.



monitoring change over time, and assessmentof outcomes. These categories are notmutually exclusive, and a single instrumentmay span several of them.

Screening instruments are used to assist indetermining whether a clinically meaningfulproblem exists that may warrant furtherservices or more extensive assessment. This“case finding” function is one of the mostcommon applications of RAIs, and becauseof the extreme brevity of many screeningmeasures, multiple instruments may beadministered in a short amount of time tocheck for a variety of problems. The four-item CAGE is a commonly used screeningtool for problem drinking, and the Single-Item Depression Screener has been found tohave comparable accuracy to lengthy mea-sures in detecting depression in elderlyclients.

Readiness for change measures are designedto evaluate whether commencement ofservices is appropriate, based on clients’recognition of the need for intervention and/or their willingness to participate. These aremost commonly, though not exclusively, usedin addiction services, where client denial canbe a serious barrier to progress. The Univer-sity of Rhode Island Change Assessment(URICA) is an example of a client-readinessinstrument applied to substance-use prob-lems, as well as to other areas, such as childmaltreatment and spouse abuse.

Diagnostic assessment measures are able toprovide results that allow classification ofclient problems or behaviors into formaldiagnostic categories, or that providecaseness scores, which indicate the probabil-ity that a particular diagnosis exists. Diagnos-tic RAIs are rare, but one important exampleis the Composite International DiagnosticInterview - Short Form (CIDI-SF) producedby the World Health Organization. It is aninterview schedule comprising four modulesthat address major depression, anxiety, andalcohol and drug disorders.

Each module begins with a stem questionthat, if answered in a certain way, triggerssubsequent items pertaining to the specificdisorder. Different clients are thus askedvarying numbers of questions, depending onwhether their answers to stem questions leadto others in each module. The entire inter-view can be completed on clients who haveno serious problems in these areas in anaverage of only a few minutes. Those who dohave problems in one or more areas will takelonger to complete the form, but the resultwill be a true diagnostic score (in the case ofanxiety) or a probability of a diagnosis.Contingency-based measures like this arebecoming increasingly common, and areoften paired with computer administrationand scoring programs.

Non-diagnostic assessment instruments differfrom screeners in that, though they may bevery brief, they do not focus solely on casefinding and can be more broadly used fortreatment planning as well. They also differfrom diagnostic assessment instruments;though they may be designed to detect clientproblems that are of clinical concern, they doso without the intent of placing the problemin a formal diagnostic framework such as theDSM-IV.

Many measures developed by social workresearchers fall into this group, includingthose in Walter Hudson’s Clinical Measure-ment Package, such as the GeneralizedContentment Scale (GCS) and Index of Self-Esteem (ISE). Other instruments in thiscategory are designed to measure problems orstrengths in social and family relations. TheInterpersonal Support Evaluation List (ISEL)is a frequently used measure of social sup-port, for example, while instruments such asthe Family Environment Scale (FES),Parenting Stress Index (PSI), and ConflictTactics Scale (CTS) measure various aspectsof family functioning.

Also included in this category are measures ofclient attitudes or personality traits that may


See Rapid Assessment Instruments, Page 14

have only indirect clinical relevance, but canbe useful in understanding an individual orgroup. Examples include prejudicial attitudes(Modern Racism Scale [MRS]), guilt orshame (Test of Self-Conscious Affect[TOSCA]), Type-A behavior pattern (theFramingham Scale), narcissism (NarcissisticPersonality Inventory [NPI]), and manyothers.

Measures for monitoring change over timetrack improvement or deterioration in clientfunctioning through repeated administrationsduring services. Typical features are brevity(so clients grow less tired of completing theinstrument), stability (as evidenced by goodtest-retest reliability), and freedom from“response set” problems that occur whenclients’ scores are influenced more by theirprevious answers than by how they actuallyfeel. Many instruments from the screeningand non-diagnostic assessment category maybe used for this purpose, but others havebeen specially designed. Two examples arethe Treatment Services Review (TSR), whichwas designed for substance-abuse treatmentprograms, and the Life Skills Profile (LSP),used in psychiatric rehabilitation.

Outcome measures are administered near to,or following, service completion, usually withthe goal of assessing the effectiveness ofservices. Measures from many of the catego-ries above may be used for this purpose, butothers are specifically targeted toward posthoc assessment. Some seek to provideinformation on whether the client’s function-ing has been brought to within normalranges.

One example of these is the Behavior andSymptom Identification Scale (BASIS-32),which has been widely used to evaluateclinical effectiveness in mental health services.Instruments to measure satisfaction withservices are another frequently used measurein this category. The Client SatisfactionQuestionnaire (CSQ-8), though originally

designed for use in mental health, has beenused in a variety of service settings.

Identifying and SelectingMeasures and ObtainingCopiesNo single source exists to which practitionerscan turn when searching for brief measures.Instead, anthologies and compilations havetended to focus on different subsets of thevast body of standardized scales in existence.Box 1 lists some examples. The test bankmaintained by Educational Testing Services,which offers a searchable database (at: http://www.ets.org/testcoll/) is a useful onlinesource.

Authors of new measures are expected toconduct empirical tests of their propertiesand performance and to publish the results.This usually occurs in journal articles, butmay also be found in books or book chap-ters. This key reference is typically the beststarting place when gathering informationabout a measure of interest.

Many of the most-used measures designed forclinical applications are marketed commer-cially. Names and Web addresses of a sampleof scale publishers are shown in Box 2. Thecost of instruments marketed by these firmsrange from 10 cents to more than $5 percopy, depending on length, scoring, supple-mentary materials, and other factors. Manu-als describing administration, scoring, norms,and measurement properties must usually bepurchased as well, and these vary in pricefrom a few dollars to over $100. However,though costly, commercial measures are oftenbetter studied and initially tested on morediverse populations than others.

Some instruments are not marketed commer-cially, but are copyrighted by their authors.Others, if they are reprinted in their entirety



in the key reference, may be copyrighted bythe publisher of the work in which the keyreference appeared. In either case, permissionto reproduce must be obtained from thecopyright holder prior to use. Makingcontact with the author is also recommendedas a means of determining if revisions havebeen made to the measure or if versions inother languages are available. Finally, somemeasures are in the public domain and maybe copied and administered at will.

RAIs as Tools for SocialWorkersKnowing how to find and appropriately useRAIs is an important skill for social workersin a variety of practice arenas. For example,the use of RAIs in problem screening inmulti-service settings can be of great value.Many people come in contact with an agencyfor a particular problem (e.g., child maltreat-ment, substance abuse, domestic violence,mental health concerns), but the earlyadministration of a brief , multidimensionalscreening tool may identify underlying orancillary problems that might otherwise bemissed. Such uses allow for more accurateassessments without requiring staff to beexperts in all areas.

Social workers often rely on clinical judgmentto make these determinations, but the qualityof these judgments depends on variables suchas clinician experience, contact time withclients, and the quality of worker/clientrelationships. Clinician judgment can also beaffected by lack of familiarity with particularclient problems or populations. RAIs areintended not to supplant clinician judgments,but to provide a further means of ensuringtheir validity.

The use of RAIs to assess need, monitorchange, and evaluate outcome is consistentwith reliance on goal setting and mutual caseplanning for meeting these goals. It is also inthe best tradition of social work values thatencourage client self-determination, empow-

erment, and the working alliance betweenpractitioner and client. We are in a period inwhich the already prodigious number andrange of brief measures continues to expandand even to accelerate. Training in theselection and use of RAIs must thus be astandard curricular component in social workeducation, not only with respect to degreetraining but also in continuing education.

It is important to dispel the notion that socialworkers lack the skill or professional qualifi-cations to employ such measures. RAIs arenot customarily designed for formal diagnosiswithin frameworks such as the DSM-IV, orfor determining how clients fit within com-plex personality models. They also do notinclude projective tests such as the Rorschachor TAT that require subjective judgments andrely on interpretive analyses. Instead, RAIstend to focus on individual behaviors,characteristics, attitudes, or problems, and onproviding a quantitative score indicating thefrequency, intensity, or duration thereof.Many are deliberately designed formultidisciplinary use, while others have beenspecially developed by social workers for useby other social workers. Commercial publish-ers do require specific professional credentialsin order to purchase, administer, and inter-pret certain measures, but licensed socialwork professionals typically qualify for allbut a few of these qualification levels.

Practice ethics require that clients have aright to assume the help their social workerprovides is informed, up-to-date, and has areasonable expectation of successful out-come. Toward this end, social workers mustbe diligent in ensuring that their professionaltoolbox is stocked with the best equipmentpossible, and RAIs will likely increase in theirimportance as examples of this equipment.We believe it is critical for the field as awhole that social workers become not merelyconsumers of these tools, but active partici-pants in their ongoing development andrefinement.


Steven L. McMurtry, PhD, [email protected] andSusan J. Rose, PhD, [email protected] are on thefaculty of the Helen Bader School of Social Welfare atUniversity of Wisconsin-Milwaukee.

GeneralConoley, J. C. & Impara, J. C. (1938-2003). The mental

measurements yearbook (Volumes 1-15). Lincoln, NE:The Buros Institute of Mental Measurements of theUniversity of Nebraska-Lincoln.

Corcoran, K. & Fischer, J. (2000). Measures for clinicalpractice: A sourcebook. Volume 1: Couples, families,and children and Volume 2: Adults (3rd ed.). NewYork: Free Press.

Keyser, D. J. & Sweetland, R. C. (1984-1997). Testcritiques (Volumes 1-11). Austin, TX: Pro-Ed.

Maddox, T. (1997). Tests: A comprehensive reference forassessments in psychology, education, and business(4th ed.). Austin, TX: Pro-Ed.

Murphy, L. L., Conoley, J. C. & Impara, J. C. (1994).Tests in print IV (Volumes 1 and 2). Lincoln, NE: TheBuros Institute of Mental Measurements of theUniversity of Nebraska-Lincoln.

Robinson, J. P., Shaver, P., & Wrightsman, L. S. (1991).Measures of personality and social psychologicalattitudes. San Diego: Academic Press.

Schutte, N. S. & Malouff, J. M. (1995). Sourcebook ofadult assessment strategies. New York: Plenum Press.

Topic-SpecificAllen, J. P. & Columbus, M. (Eds.) (1995). Assessing

alcohol problems: A guide for clinicians andresearchers. Bethesda, MD: U.S. Dept. of Health andHuman Services, Public Health Service, NationalInstitutes of Health, National Institute on AlcoholAbuse and Alcoholism.

Antony, M. M., Orsillo, S. M., & Roemer, L. (Eds.)(2001). Practitioner’s guide to empirically basedmeasures of anxiety. New York: Kluwer/Plenum.

Byrne, B. M. (1996). Measuring self-concept across thelife span: Issues and instrumentation. Washington,DC: American Psychological Association.

Goldberger, L. & Breznitz, S. (1993). Handbook ofstress: Theoretical and clinical aspects. New York:Free Press.

Kane, R. L. & Kane, R. A. (Eds.) (2000). Assessing olderpersons: Measures, meaning, and practical applica-tions. New York: Oxford University Press.

McLean, P. D. & Woody, S. R. (2000). Anxiety disordersin adults: An evidence-based approach to psychologi-cal treatment. New York: Oxford University Press.

Nezu, A. M. (2000). Practitioner’s guide to empiricallybased measures of depression. New York: Kluwer/Plenum.

Rush, A. J., Pincus, H. A., First, M. B., Blacker, D.,Endicott, J., Keith, S. J., Phillips, K. A., Ryan, N. D.,Smith, G. R., Tsuang, M. T., Widiger, T. A., & Zarin,D. A. (Eds.) (2000). Handbook of psychiatricmeasures. Arlington, VA: American PsychiatricAssociation.

Snyder, C. R. (2000). Handbook of hope: Theory,measures, and applications. San Diego, CA:Academic Press.

Zalaquett, C. P. & Wood, R. J. (Eds.) (1997). Evaluatingstress: A book of resources. Lanham, MD: ScarecrowPress.

BOX 1: COMPILATIONS AND SOURCEBOOKS OF MEASURES

Contents of this report are adapted with permissionfrom McMurtry, S. L., Rose, S. J., & Cisler, R. A.(Forthcoming). Desk Reference Guide to RapidAssessment Instruments. New York: Guilford.Copyright by Steven L. McMurtry, Susan J. Rose, andRon A. Cisler. All rights reserved.

BOX 2: COMMERCIAL SCALE PUBLISHERS

• Consulting Psychologists Press: www.cpp-db.com

• EdITS: www.edits.net

• Mind Garden: www.mindgarden.com

• Multi-Health Systems: www.mhs.com

• Pearson Assessments (formerly NCS Assessments):www.pearsonassessments.com

• Pro-Ed: www.proedinc.com

• Psychological Assessment Resources, Inc.:www.parinc.com

• The Psychological Corporation: www.psychcorp.com

• Walmyr Publishing: www.walmyr.com

• Western Psychological Services: www.wpspublish.com

Non Profit Org.U.S. Postage

PAIDWashington, DCPermit No. 8213

750 First Street, NE, Suite 700Washington, DC 20002-4241

N A S W S P SNational Association of Social WorkersSpecialty Practice Sections

Editor, from Page 2

health center serving several Iowa counties. A copy ofthe Annual Reassessment and Social History Survey usedby Mr. Smith is provided as a template for practitionersseeking to maintain current client information in a time-efficient way.

• Focus on Ethics in Practice debuts in this issue, and willbe a regular column. Gail M. Johnson, MSW, LCSW is apractitioner-educator with a longstanding interest inprofessional ethics. In this issue, our resident ethicistexamines the in vivo link between ethics and competentuse of standardized measures. Ms. Johnson refers to theWisconsin experience, and encourages an informationexchange via our Mental Health Section’s “OnlineForum.”

You are the Power behind this SectionWe hope these articles will spark your clinical interest, bepractice-relevant, encourage further exploration, and

possibly even motivate you to submit an article or bookreview pertaining to an area of mental health services thatinterests you. The second issue of the 2004 Mental HealthSection Connection will focus on practice-relevant tools andmodels for use in child and adolescent mental health ser-vices. You are invited to submit a paper for that issue, whichis slated for publication in the summer. In a very real way,you are the power behind this section, and we rely on yourinput to keep us on track with current social work needs. Inour efforts to build a supportive infrastructure for socialworkers in mental health across the U.S., your feedback andpractice contributions are genuinely valued.

Aloha and Warm Regards!

Lana Sue Ka‘opua, PhD, ACSWMental Health Specialty Practice Section Committee andEditor

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