Chapter Eleven Addressing and Disarming Anger Fundamentals of Case Management Practice: Skills for the Human Services, 4th Edition Nancy Summers 2012

COMMON REASONS FOR ANGER The client is angry about something the agency has done. The client is angry about something you have said or done. The client is fearful about the way his life is going. The client is exhausted from trying to cope. The client feels overwhelmed by the problems. The client is confused by all the policies, circumstances, others’ reactions to her. The client feels a need for attention and attempts to obtain it with anger.

WHY DISARMING ANGER IS IMPORTANT Eliminates an obstacle to true understanding. Shows the client you respect the message. Enables you to understand the problem. Disarming anger also: Enables you to understand the problem. Allows you to practice empathy. Focuses on solving the issues and problems.

DO NOT TAKE CLIENTS’ ANGER PERSONALLY This is the number one mistake workers make when dealing with angry clients. There are numerous reasons clients become angry that have nothing to do with us. Taking anger personally may cause you to say or do things that will permanently damage your relationship with the client. Even when you believe the client is angry with you move on to looking for a solution with the client.

ERRONEOUS EXPECTATIONS FOR PERFECT COMMUNICATION It is not realistic to expect that clients will: Never get angry, particularly with us. Always be appreciative. Never raise doubts. Not criticize us. Not resist our ideas or even plans we developed with them. Believing these things is a trap. We become disillusioned with the work and the client and tend to treat the client punitively or with exasperation.

DISARMING ANGER IS A FOUR-STEP PROCESS Disarming anger is a four-step process 1. Be appreciative: “Thanks for letting me know this.” or “I appreciate your feeling you could share this with me.” 2. Ask for more information without grilling: “Can you tell me more about when this happened?” 3. Find something with which you can agree: “I can see how we missed this when we went over the other clients appointments.” 4. Begin to focus on a solution: “I have some thoughts about how we could avoid this in the future. What are some of your ideas?”

WHAT YOU DO NOT WANT TO DO Do not become defensive - defending yourself makes others angry and you lose the opportunity to solve the problem. Do not become sarcastic or facetious - when you thank clients for their comments or agree with something you could sound sarcastic, especially if you are feeling defensive. Do not act superior - accept that it is alright for you to be wrong in your perceptions or your behavior and it is alright for the client to be wrong too. Do not grill the client - when you ask questions for a better understanding don’t ask one after the other in a doubtful tone.

LOOK FOR USEFUL INFORMATION If you listen to the message and not the anger, you can benefit from useful feedback you may be getting. Sometimes the client is bringing useful information that will help you or your agency make constructive changes.

MANAGING AN ANGRY OUTBURST Be concerned when people move to anger that seems about to be out of control, involves threats to others, or actual aggression. Staff play a role in diffusing such a situation. Use: 1. an even tone of voice 2. reflective listening, and 3. relaxed movement Remain calm

Chapter Twelve The Effective Combination of Skills Fundamentals of Case Management Practice: Skills for the Human Services, 4th Edition Nancy Summers 1012

SKILLS AND ATTITUDES YOU HAVE LEARNED SO FAR Acceptance of clients where they are. Informed consent to engage clients in the decisions. Self-determination - a respect for the client’s choices. Individualized planning. Cultural competence. Adopting a non-judgmental attitude. Collaboration with clients. Motivating and encouraging. The Recovery Model wherein we look beyond the immediate problem to a more wholesome and satisfactory life. Seeing ourselves as separate. Reflective listening. Open questions. I messages. Disarming anger.

SKILLS THAT FACILITATE CHANGE PART I Make it safe to explore - Invite the client to explore the problem by showing your interest. “What do you feel we should address first?” Steer around initial worries - help clients put aside their concerns that what may come of their contact with you won’t work. “You are way ahead of me. I just want to know what your thoughts are about this problem.”

SKILLS THAT FACILITATE CHANGE PART II Articulate self-determination - help clients understand that they are in charge of what takes place. “In the end you will decide whether we do this or not. Help people talk about change - Rather than you telling clients why they should change get them to tell you why they should change. “Tell me a little bit about how you would like things to be.

SKILLS THAT FACILITATE CHANGE PART III Discuss discrepancies - Discuss the difference between the way things are and the way the client would like them to be. Allow the person to talk about why it would be an advantage to change. Allow people to express discrepancies - Allow people to feel ambivalent about change.

SKILLS THAT FACILITATE CHANGE PART IV Bring out confidence - Ask for expressions of confidence. “Tell me what strengths you have that will help you to make this change.” Facilitate commitment - Ask for expressions of commitment. “Tell me what you would be willing to try at this point.” Reflect the opposite side - without sarcasm use reflective listening to the client’s reluctance and reflect that back. Often the client will then counter the reluctance.

AMBIVALENCE Ambivalence is normal when people face change Accept ambivalence matter-of-factly when it occurs Allow clients to express ambivalence Respond to the feelings and content of their ambivalent statements as you would to any thing the client has said Avoid arguing for change, thus forcing the client to argue for the status quo

TRAPPING THE CLIENT Arguing with clients will not help clients to change. Telling clients what bad or incompetent people they are will not make clients better able to change. Clients need a safe environment to change. That safe environment includes someone who will listen to them vacillate between change that the status quo. Arguing and denigrating trap the client in the old ways of being.

FROM ADVERSARIAL TO COLLABORATIVE Brainstorming - list, without judgment, as many ideas as you both can think of for making changes. Offering information and advice - do so only after hearing the client’s ideas, ask permission to do so, and make sure what you have to offer is truly going to be helpful.

SUMMARIZING Summarizing - we are reflecting back important points clients need to hear again 1. Collecting summaries - pull together the important points in a discussion. 2. Linking summaries - pull together the important points from the entire interview and link these together. 3. Transition summaries - prepare the client to move forward, sometimes to the next interview.

CASE MANAGER TRAPS Coming off as a know-it-all - You may have a lot of answers but clients are more likely to change if you give them space and collaborate. Labeling a person as resistant - It is better to view a client’s reluctance to take important steps as ambivalence. Use reflective listening. Arguing - Clients are more likely to become defensive of the way they are and not be able to move forward to change. Seeing the client as hopeless - clients who argue against change may not be dead set against it. Instead they may be letting us know they have no real hope for change.

Chapter Thirteen Putting it all Together Fundamentals of Case Management Practice: Skills for the Human Services, 4th Edition Nancy Summers 1012

AFTER DOING EXERCISE I Why was it a good idea for you to start with an open question in this situation? When you responded with reflective listening to the woman’s feelings, you were letting her know what? Was an I message warranted in this situation? Why? What might you have said to the family of the woman to let them know you heard their concerns and frustrations?

AFTER DOING EXERCISE II Why did you start this interview with an open question? Several times you used reflective listening. Look at the times you did that and decide what purpose these responses served. Why did you ask an open question about his supports other than Goodwill rather than using a direct question? When you responded to the content of the man’s comments (#9) why was that useful? Did you think there was collaboration going on here? If so where did you see it?

AFTER DOING EXERCISE III After Mrs. Sylvestri tells you about her son why did you use reflective listening? What purpose did that serve? Why did you ask her an open question about her deceased husband? Why did you use an I message to suggest Arbor House, rather than just making the suggestion? Why is it important to collaborate with Mrs. Sylvestri? Do you think rapport was established in this interview? Specifically, how did that happen?

AFTER DOING EXERCISE IV How did you feel when someone was listening to you using these skills? What did you notice about your partner when your partner was the client and you used these skills to conduct the interview? Where did you feel you needed improvement in the skills? Is there a specific skill that you need to practice?

Chapter Fourteen Documenting Initial Inquiries Fundamentals of Case Management Practice: Skills for the Human Services, 4th Edition Nancy Summers 1012

FILLING OUT THE NEW REFERRAL OR INQUIRY FORM, STEPS 2 & 3 Place a home phone number on the form, and the work number of the client if the client is working. The person will either: a. be a minor and have a parent or guardian, in which case you circle or underline “parent” on the form and write in the name of the parent, or b. be an adult with a spouse, in which case you underline or circle “spouse” on the form and write in the name of the spouse, or c. be neither of these, in which case you write N/A in big letters on that line. Steps for Filling Out the New Referral or Inquiry Form A typical form for phone inquiries is found in the Appendix. It is titled “New Referral or Inquiry.” The following is a step-by-step process for filling out this form. Make a photocopy of the blank form in the Appendix at the back of this book, and fill it out by following these steps: 1. Place the client’s name, sex, date of birth, and address at the top of the form. 2. Place a home phone number on the form, and the work number of the client if the client is working. 3. The person will either: a. be a minor and have a parent or guardian, in which case you circle or underline “parent” on the form and write in the name of the parent, or b. be an adult with a spouse, in which case you underline or circle “spouse” on the form and write in the name of the spouse, or c. be neither of these, in which case you write N/A in big letters on that line. 4. If the person is employed, place the name of the employer on that line. If the person is not employed, place N/A on that line. 5. If the person is in school, place the name of the school (complete with what kind of school—college, elementary school, high school) on that line. If the person is not in school, place N/A on that line. 6. The client will either be: a. a self-referral, meaning the person found out about your agency through the phone book or a friend and called in on his own. If that is the case, write “self” on that line. Most calls are self-referrals, or b. referred by a doctor or other professional. In that case, place that person’s name on the line. You are asking the client, “Who referred you to our services?” Answers might be Dr. Graham Smith or Attorney William Burns. 7. Under the section marked “Chief Complaint,” always tell why the person called today. Do not say the person called today because her husband is abusing her. The husband may be abusing her, but what made her go to the phone today? Here are some reasons people might give for calling today: - Today the person decided she cannot go on. - This morning, his employer insisted he get help. - She saw a medical doctor within the last 48 hours who told her she needs counseling. - He just had a fight with his spouse and is afraid of what he might do. - He just hit his child. - She thinks she will hit her child and has called for help to stop herself. In filling out the “Chief Complaint” section, capture why the person called on this date and not on some other day. Begin this section with “Client (or the person’s name) called today because . . .” Capturing the Highlights of the Chief Complaint You have a small space and can use very few sentences to describe why the client called today and not some other day. In thinking about what the client has told you about why she called, choose the most important points. Here are some examples: .

FILLING OUT THE NEW REFERRAL OR INQUIRY FORM, STEPS 4 & 5 If the person is employed, place the name of the employer on that line. If the person is not employed, place N/A on that line. If the person is in school, place the name of the school (complete with what kind of school—college, elementary school, high school) on that line. If the person is not in school, place N/A on that line.

FILLING OUT THE NEW REFERRAL OR INQUIRY FORM, STEPS 6 & 7 The client will either be: a. a self-referral, meaning the person found out about your agency through the phone book or a friend and called in on his own. If that is the case, write “self” on that line. Most calls are self-referrals or b, referred by a doctor or other professional. In that case, place that person’s name on the line. You are asking the client, “Who referred you to our services?” Answers might be Dr. Graham Smith or Attorney William Burns. Under the section marked “Chief Complaint,” always tell why the person called today. Do not say the person called today because her husband is abusing her. The husband may be abusing her, but what made her go to the phone today?

FILLING OUT THE NEW REFERRAL OR INQUIRY FORM, STEPS 8 & 9 Under “Previous Treatment,” keep the notes brief—just note when, where (and with whom if you know that), and for what. Keep from being too wordy in this section. The intake is “taken by” you. This is the first place your name is to appear on this form! Put the date of the intake next to your name.

FILLING OUT THE NEW REFERRAL OR INQUIRY FORM, STEP 10 Under “Disposition,” note the name of the person to whom you refer the new client for intake and the date of the intake appointment. In many settings, the person who handles the phone inquiries is not the same person who sees the clients when they come in for their first appointments. For training purposes, we will assume that you will be doing both the phone inquiry and the client intake, in which case you would write your own name, along with the date of the intake appointment, on that line.

FILLING OUT THE NEW REFERRAL OR INQUIRY FORM, STEP 11 Under “Verification Sent,” write “Yes” and the date. The date you use here is the date you send out the verification form, usually the same day on which you take the phone inquiry.

AFTER THE FORM IS FILLED OUT After a person has inquired about services from your agency, it is important to bring the person in for a more thorough history and evaluation of the problem, if the person is seeking services. You will set up an appointment for the caller on the phone at the time of the call or soon after you hang up. The next step is to send a letter verifying or confirming this appointment.

CAPTURING HIGHLIGHTS OF THE CHIEF COMPLAINT Keep the reasons from being too complicated - Do not create clients who are experiencing a psychiatric emergency. Be very specific - Give specific facts of the clients problem (when, where, how often, what is going on currently). Do not use vague general descriptions. Keep the reasons for the call brief - On this form give only the immediate details. Save the detailed background information for the social history you take from the client in person.

EVALUATING THE CLIENT’S MOTIVATION AND MOOD Always end your chief complaint section with a sentence or two about how the client sounded on the phone or how the client seemed to you. Does the client sound animated or depressed? Does the client speak normally or seem pressured or vague? Does the client seem to want to get help or use the services? Did the client tell you how he or she is feeling?

FILLING OUT THE VERIFICATION OF APPOINTMENT FORM On the Verification form, be sure that the date you send it out is the same date you said you sent it out on your New Referral or Inquiry form. Be sure to address the client by name. Fill in the date, time, staff, and location of the interview. The date is the date you listed under “disposition” on the inquiry form. You can decide on a time. The staff person will be you. The interview will take place at the Wildwood Center. Sign your name. Your signature should line up precisely under “Sincerely” and over “Case Manager.” Do not sign out to the right.

Chapter Fifteen The First Interview Fundamentals of Case Management Practice: Skills for the Human Services, 4th Edition Nancy Summers 1012

YOUR ROLE IN THE FIRST INTERVIEW Listen and convey and accurate understanding of clients’ perceptions about themselves and their problems. This is done using reflective listening. Formulate a professional understanding of what it is the client is experiencing and what this person will need while being served by your agency. Strive to establish rapport with clients so that they feel comfortable with you and with your agency.

PREPARING FOR THE FIRST INTERVIEW Look at the intake material. Check past agency records. Look at past medical history. Keep in mind the material was collected by others who saw the client under very different circumstances. Make sure your office is a comfortable place in which to confide in another person.

MEETING THE CLIENT Go out to the waiting room to meet the client. Introduce yourself, using your full name. Make a mental note of your first impressions of the client. Make a mental note of the clients reactions to you and the situation Show an interest in what the client has to say. If asked, give your credentials. Point out respectfully, if asked personal questions, that the interview is about the client, not about you. Describe the agency and its purpose. Make sure payment arrangements have been explained. Make sure confidentiality limitations and policies have been explained.

WHAT TO DO AS CLIENTS DESCRIBE THEIR ISSUES It is alright to take notes. Note-taking ensures accuracy Allow clients to tell the story in their own way. Encourage the client to talk about their issues by using open questions and reflective listening. EXAMPLES: So the last 8 months have really been difficult with your mother. Tell me a little bit about what’s been happening with her.

JUDGING AND CLARIFYING Avoid judging clients who may have different values or lifestyles from your own. To seek more clarification use open questions. EXAMPLE: Can you tell me more about your sister’s comments that evening? Refrain from using why questions which may sound like prying or ask for a level of understanding the client does not have.

WHAT INFORMATION TO COLLECT Seek to understand why the client is here now as opposed to last week or last month. What happened to bring the client in now. Document: the client’s presenting problem. This is generally what brought the client to the agency. The extent to which the problem has interfered with the client’s ability to function. The support system the client has or does not have. What the client is expecting as a result of coming to the agency.

CLIENT EXPECTATIONS Clients or their guardians should participate in the planning Ask people what it is they would like from your agency Often they will not know what services are available or what they need Explore together what treatment or service options there are for the client

WRAPPING UP Ask clients if they have any questions they want to ask you. With the client define the problem in language they understand. Verify what the client is expecting. Tell the client what will happen next. Give the client an appointment card if there is to be a next appointment. Rise at the end of the interview to indicate the interview is complete. Do not allow clients to leave if you think they are considering harming themselves or someone else. After clients leave do not talk about them where other clients can overhear you.