MODULE

ASSESSMENT, CARE PLANNING & MONITORING 07

07
 MODULE 7 ASSESSMENT, CARE PLANNING & MONITORING

Introduction
In this module case managers will learn about how to conduct strengths-based, bio-psychosocial
assessments. An emphasis will be placed on how case managers need to collaborate with clients in
selecting priorities for care and in setting goals and strategies for change. Case managers’ roles in
assessing progress and obtaining client feedback are also covered.

Learning Objectives
The learning objectives for this module are:
• Explain procedures and documentation for strengths-based, bio-psychosocial assessment
• Emphasize the importance of client-centered care planning
• Practice interviewing for assessment and motivational interviewing, goal-setting, and care plan
development
• Outline requirements for case managers to assess clients’ progress and obtain client feedback

Expected competencies
By the end of this module participants will:
• Understand how to conduct bio-psychosocial assessments
• Further develop skills in strengths-based interviewing
• Understand the principles of motivational interviewing and the stages of change
• Be able to employ the motivational interviewing technique
• Appreciate the importance of positive, concrete, observable, measurable, goal-setting and know
effective ways to collaborate with clients to set these
• Understand how to monitor and track clients’ progress and obtain client feedback
• Be able to use IMC assessment, care planning, and case-monitoring documentation and reporting

Module Timings
Estimated preparation time for trainer: 0.5 hour
Estimated Module Session time: 6 hours (3hr core content, 3hr exercises)

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Module Assessment
The following competencies will be assessed in module tests:
• Understand how to conduct bio-psychosocial assessments
• Understand the principles of motivational interviewing and the stages of change
• Identify the importance of positive, concrete, observable, measurable, goal-setting and know
effective ways to collaborate with clients to set these

The following competencies will be assessed by supervisor observation and discussion:

• Obtains client consent (verbally or written) as appropriate
• Exhibits effective interviewing and clinical skills (e.g. showing interest, affirming clients’ strengths,
engages both client and relative as appropriate, cross validates findings, ensures clients’
understanding of findings and recommendations)
• Displays competencies in motivational interviewing (e.g. developing discrepancy, avoiding
argumentation, rolling with resistance, expressing sympathy, supporting self-efficacy)
• Fills out the complete IMC bio-psychosocial assessment form at intake
• Summarizes their own impression based on the knowledge and information gained in the assessment
and records this on the assessment form
• Assesses for potential of high risk behaviors (e.g. thoughts about hurting self or someone else)
• Generates care plan for each client
• Asks questions from the client to obtain input into their care plan
• Documents all case management activities in the client records in a timely manner
• Ensures that all services and activities provided are tracked using IMC reporting forms
• Documents client progress regularly (e.g. baseline + periodic wellbeing and functioning, patient
satisfaction surveys)

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ASSESSMENT, CARE PLANNING, & MONITORING

Skills for Conducting Intake and Assessment

Motivational Interviewing
Intake Process and Forms
Biopsychosocial Assessment Process and Forms
Developing Goals and Objectives
Care Planning Process and Forms
Monitoring

We have explored important communication skills that case managers will be required to use when
conducting intake and assessment interviews with clients. These include building rapport, respect, and
trust with your client. To begin this section, we will practice these skills.

Activity#1. Building Rapport

Divide participants into three teams. Have each team brainstorm how to build one of the following:
• Rapport
• Respect
• Trust
Ask case managers what they do with a new client to try to establish a good relationship and write
responses on flip chart. Validate these responses and ideas as they are given; case managers can use
this as an opportunity to learn from each other’s experiences. Include the following suggestions in the
discussion:
Introduce yourself.
Ask how the client would like to be addressed.
Ask open-ended questions to avoid making the clients feel that they are being interrogated.
Show respect for the client by using verbal and non-verbal messages to communicate understanding
and acceptance (if culturally appropriate, smile and make eye contact).
Additionally, case managers should: be on time for appointments, give the clients their full attention, listen
attentively, use empathic responses, remember the client’s name, and be genuine in their concern and
desire to help1

1 Hepworth, Rooney, Rooney & Strom-Gottfried. Direct Social Work Practice: Theory and Skills 9th Edition. [2010] p. 48-49
3
Motivational Interviewing
Motivational Interviewing (MI) is a focused approach that originated for the treatment of addictive behaviors,
and has since been expanded to address issues of the general process of change. Motivational Interviewing
is defined as a collaborative, person-centered form of guidance to elicit and strengthen motivation for
change . It does not attempt to force people to change 2, but it helps to draw out the internal motivation
the person already has. MI is concerned with the person’s own perspective, but does not just involve
following the person, it moves them along in the direction of change. While conducting this type of therapy,
as with any other kind of therapy, it is important to remember to be respectful of the person’s thoughts
and opinions.

The spirit of MI is based on principles in line with those of our mental health case management approach:
• Collaboration and mutual understanding between service provider and client [Participation].
• Evoking the client’s ideas about change, which is more powerful and sustainable then the service
provider telling the client what to do [Strengths and Participation].
• Autonomy (vs. authority) recognizes that the true power for change lies with the client. Clients are
encouraged to develop a range of options to help them change [Self-determination, Participation]3

Guidelines on Motivational Interviewing

There are five general guidelines to adhere to when conducting motivational interviewing:
• Expressing empathy
• Supporting self-efficacy
• Rolling with resistance
• Developing discrepancy
• Exploring pros and cons 4

Expressing empathy
Motivational Interviewing requires expressing empathy. Seeing the world as the client sees it through skillful,
reflective listening is fundamental when conducting Motivational Interviewing. Ambivalence is normal; be
sure to respond to it as understandable, comprehensible, and valid. Acceptance facilitates change, and
accepting the client as they are can help them to move towards change.

Supporting self-efficacy
MI is a strengths-based approach which is conducted with the belief that people have the capacity to
change within themselves. Belief in the possibility of change is an important motivator.
2 Agency for Health Care Policy and Research. Smoking Cessation: Clinical Practice Guideline, Number 18. Washington, DC: U.S. Government Printing
Office, 1996.
3 Bandura, A. Human agency in social cognitive theory. American Psychologist. 1989;44:1175-1184 [PubMed]
4 4 Bandura, A. Self-Efficacy: The Exercise of Control. New York: W.H. Freeman, 1997.
The client is responsible for choosing and carrying out personal change, and hope can often be found
in the range of alternative approaches that are available. The case manager makes a point to encourage
people based on the abilities and resources that they possess. This may be accomplished in a number
of ways. The technique of self-efficacy by exploring past successes with clients to reduce or change
negative patterns is often effective. Questions such as, "What worked?" and, "What was it that enabled
you to be successful that time?" can be useful in discovering various strengths and aspects that are keys
to success. Lessons learned from previous unsuccessful attempts to change are also a rich source of
efficacy in the hands of a skillful interviewer. Facilitate the client’s self-efficacy by allowing them to choose
their own direction and come up with their own solutions. This can increase a client’s confidence in their
abilities to create change. 5

Rolling with resistance

The third technique is rolling with resistance. If a client exhibits resistance, try to understand where it is
coming from. There is likely a good reason that the client is resistant to change. Rather than meeting client
resistance with confrontation (e.g. ‘correcting’ or ‘righting’ the client), providers are encouraged to utilize
reflection in an effort to decrease it whenever possible. For example, when a client is brought to an IMC
Mental Health clinic or Protection clinic to see you by their family, the client may come right out and say,
"I don't need to be here and I'm not happy about being forced to come." You might respond with, "I hear
you loud and clear, you're not happy about being here and this seems like a waste of your time?" When
clients are resistant, angry, or otherwise needing to make a point, rolling with these episodes increases the
likelihood that people will remain engaged and potentially more receptive to those aspects of the treatment
process that they find helpful. Remember that clients can find their own solutions. If a client is resistant, ask
them what might work instead. Perceptions can always be shifted and examining an issue from another
angle may be all that is needed to tip the balance of ambivalence. 6

Developing discrepancy
The technique of developing discrepancy is used to point out ambivalence. Discrepancy is when a client
has inconsistency in their life. When utilizing this technique, the case manager highlights each side of a
discrepancy or a conflict related to the client’s desired change. For example, if the client says that they
might feel better with exercise, but also says that they do not want to leave the house, the case manager
can ask, “So, you might feel better if you exercise but you don’t want to leave the house?” 7
The idea behind this technique is that a discrepancy between present behavior and important goals will
motivate change (also see section on listening reflectively and double-sided reflection).

5 Bandura, A. Self-Efficacy: The Exercise of Control. New York: W.H. Freeman, 1997.
6 Bien, T.H. "Motivational intervention with alcohol outpatients." Ph.D. diss., University of New Mexico, 1992.
7 Chamberlain, P.; Patterson, G.; Reid, J.; Kavanaugh, K.; and Forgatch, M. Observation of client resistance. Behavior Therapy. 1984; 15:144-155 5
Knowing goals and values: in developing discrepancy, it is important for the case manager to gain a
deep understanding of what really matters to people both in terms of immediate and long–term life
goals. Additionally, understanding value systems is important. Once the case manager has an adequate
understanding of these areas, they will be better equipped to assist the ambivalent client with clarifying
important goals that can play a critical role in sound decision-making. It is important to highlight this
discrepancy and to remember that the change is the client’s own challenge and is not a challenge that you
can face for them.

Exploring pros and cons

It is important that the treatment provider begin the decisional balance exercise by focusing on the benefits
of the status quo first. For example, by discussing the benefits of chewing khat, the provider is more likely
to elicit costs from the client. Acknowledging that there are things about chewing khat that the individual
likes (the “good things”) makes it easier for them to consider and explore the consequences of their
chewing (the “not so good things”). The purpose of a decisional balance is to have people openly compare
the costs versus benefits of use. As a result, it is now the client who is in the position of arguing against use
instead of the other way around. The provider could ask: “Tell me more about what you like about chewing
khat?” After exploration, you can lead to: “Is there anything about it you don’t like?” 8

Motivational Interviewing skills and strategies

At times it will be appropriate to ask permission to discuss the pertinent issues. It is very unlikely that the
client will say ‘no,’ and asking permission can open the door to increased motivation for change or to the
realization of desire to change.
There are five general skills guided by the above principles that should be utilized:
1. Ask open-ended questions
It is important to ask open-ended questions rather than closed-ended questions because the answers to
open-ended questions give us more information and can explore reasons for change.
2. Use Affirmations
Affirmations offer the person praise in the form of compliments and/or statements of appreciation that
reinforce self-efficacy and client strengths. Here are a couple of examples:
• "It sounds like you've really overcome a lot; you must be a very resourceful person."
• "With all that you have going on, I really appreciate that you made it in for our session today.”
Listen for strengths and resources while your client is talking and draw them out. For example:
• Client: “Sometimes I get irritated when I chew khat and then yell at my children but then I feel bad
because I love them.”

6 8 Chamberlain, P.; Patterson, G.; Reid, J.; Kavanaugh, K.; and Forgatch, M. Observation of client resistance. Behavior Therapy. 1984; 15:144-155
 • Case manager: “You really care about your children and do not want to yell at them.” [This is
different from: “You say you yell at your children a lot when you chew khat, maybe you can try to
cut down?”]
3. Listening Reflectively
In particular, there are three types of reflections commonly used in MI: simple reflections, amplified
reflections, and double-sided reflections. Each of these reflections can be useful in encouraging people to
continue an internal exploration of their experience.
Simple reflections serve to acknowledge people's thoughts, feelings, and positions in a neutral manner
such that further exploration is facilitated. 9
• Client: “I can't believe my wife thinks I should be chewing less khat because it costs too much
money. You'd think the she would have more important things to worry about.”
• Case manager (Simple reflection): “You think that your wife should not be telling you to chew less
khat.”
• Client: “Exactly. I mean, khat does cost money but we have other things to worry about and it helps
me relax.”
By rolling with resistance and offering a simple reflection to let people know that his frustration has been
heard, the case manager has successfully opened the door to more exploration.
Amplified reflections serve to reduce the intensity of a person's stance on a given position so that the
individual is more inclined to argue for the other side of his or her ambivalence.
• Client: “I can't believe my wife keeps telling me I should be chewing less khat because it costs too
much money. You'd think the she would have more important things to worry about.”
• Case manager (Amplified reflection): “You don't think your wife has any business worrying about
money because of your khat use?”
• Client: “Well, not exactly. I know she is worried about having enough money to buy food for the
children, but it is difficult for me to cut down.”
Double-sided reflections capture both sides of a client’s ambivalence and are particularly useful in
developing discrepancy.
• Client: “I can't believe my wife keeps telling me I should be chewing less khat because it costs too
much money. You'd think the she would have more important things to worry about.”
• Case manager (Double-sided reflection): “On the one hand, you like to chew khat but on the other
hand, it also costs a lot of money.”
• Client: “Yes that's true. I don’t quite know what to do about it and my wife keeps nagging me, but
how can change if this is what helps me relax in the afternoon and evening?”

9 Bandura, A. Self-Efficacy: The Exercise of Control. New York: W.H. Freeman, 1997. 7
4. Summarizing periodically
Summaries convey to people that you have not only been listening to what they have said, but also
promote further exploration of the topic being discussed. To that end, summaries are often concluded with
open-ended questions or reflections that encourage clients to elaborate further. An example of a linking
summary might go as follows:
• “It strikes me as I've been listening to what you've said that you're torn between two different
directions. On the one hand, chewing khat helps you relax during evenings and afternoons. But
with six children at home, you and your wife are having a difficult time buying enough food for
everyone. And you also mentioned that khat sometimes makes you irritable and you yell at your
wife although you do not want to.”
• “You're clearly concerned, but feel as though you're between a rock and a hard place.”
In this example, the summary links together information from various points and encourages more
talk about change.
Be sure to utilize active listening skills when the client is speaking. Show them that you are listening by
reflecting back what is said. One of the differences for reflective listening in Motivational Interviewing,
however, is that it is important to reflect back the statements the client makes that are moving them
towards change. While these statements are highlighted, the other side needs to be acknowledged as
well in order to prevent the client from feeling as though that side needs to be defended. During discussion,
acknowledge the client’s right to choose, but listen for their desire or motivation to change.

Change Talk
Change talk is defined as: statements by the client revealing consideration of, motivation for, or
commitment to change. 10

Research shows strong links between clients' statements about change and outcomes. The more
someone talks about change, the more likely are they to change.

Table#1. Motivational Chart

Preparatory Change Talk
Most predictive of positive outcomes
Desire (I want to change)
Commitment (I will make changes)
Ability (I can change)
Activation (I am ready, prepared, willing to change)
Reason (It’s important to change)
Taking Steps (I am taking specific actions to change) 11
Need (I should change)

!
10 Bandura, A. Self-Efficacy: The Exercise of Control. New York: W.H. Freeman, 1997.
11 Ingersoll, K.S., and Wagner, C.C. Motivational Enhancement Groups for the Virginia Substance Abuse Treatment Outcomes Evaluation (SATOE) Model:
Theoretical Background and Clinical Guidelines. Richmond, VA: Office of Mental Health Services, Department of Mental Health, Mental Retardation and
8 Substance Abuse Services, 1997.
Stages of Change
Motivational Interviewing is a therapy technique that assesses a client’s motivation. What we, as case
managers, want to know is, ‘Are people interested in changing? Are they ambivalent about change? Or,
are they committed to change?’ When examining a beneficiary’s motivation, it is important to keep in mind
the five stages of change.
The first stage of change is precontemplation. Precontemplation is when a person is not even thinking
about change. People in this category tend to be defensive and do not see a need to talk about the
situation.
The second stage is contemplation. A person in this stage is beginning to think about making a change.
People in this stage tend to be ambivalent, seeing some good in the change and seeing some good in
the status quo.
The third stage is preparation. A person in this stage is getting ready to make a change and may already
be making small steps towards the change. Information gathering can occur at this stage and it is also
when the decision to make the change is made.
The fourth stage of change is action. A client is in the action stage when they have already made the
decision to change and are working towards it. The client is changing their behavior, believes in their ability
to make the change, and is actively involved in making the change.
The fifth and final stage of change is
maintenance. Someone in this stage has been PROGRESS Precontemplation

maintaining the behavior change for six months

or longer. These clients remind themselves Contemplation
of the progress they’ve made and make
successful attempts at avoiding bad habits.
Preparation
It is important to remember, however, that
progression through these stages is not always
the same. Relapse is common. When relapse Action

occurs with a client, normalize it and learn from

it. Ask the client what worked and what did not Maintenance
RELAPSE
work, so that the change may stick the next
time.12

Assessing a client’s readiness to change

Sometimes it can be difficult to recognize which stage of change a client is in. If it is not obvious through the discussion, a series

of scaling questions can be asked to determine where the client stands.

12 Ingersoll, K.S., and Wagner, C.C. Motivational Enhancement Groups for the Virginia Substance Abuse Treatment Outcomes Evaluation (SATOE) Model:
Theoretical Background and Clinical Guidelines. Richmond, VA: Office of Mental Health Services, Department of Mental Health, Mental Retardation and
Substance Abuse Services, 1997. 9
Role Play Activity. Motivational Interviewing
40 minutes
Now that we have discussed Motivational Interviewing, we are going to practice the skills and techniques
as a group through a role play with a client in different stages of change.
Ask for two volunteers, one to role play the case manager and the other to role play the client. Instruct the
volunteer role playing the the client to pretend to be someone who is stuck in the contemplation stage
and to tell everyone the problem that needs to be addressed. Give the volunteers 5-10 minutes to role
play a therapy session. If the case manager gets stuck at any point during the role play, they can turn to
the other case managers for feedback. In this case, the audience can provide the case manager with
suggestions of questions to ask next:
• What was easy or comfortable about working with this client?
• What was difficult or uncomfortable about working with this client?
• To the audience: What is something that the case manager did well?
• To the audience: What is something that the case manager could have improved upon?
The next role play in this exerceise will be done with a client who is in the preparation stage of change.
One volunteer will play the case manager and another volunteer will act as the client. The acting client
may either invent a new problem or can continue with the problem from the previous role play. If the
case manager gets stuck at any point during the role play, they can turn to the other case managers for
feedback. In this case, the audience can provide the case manager with suggestions of questions to ask
next. After 5-10 minutes, bring the group back together to address the following questions:

• How was it to meet with the client in the preparation stage? (A person in this stage is getting ready
to make a change and may already be making small steps towards the change. Information
gathering can occur at this stage and it is also when the decision to make the change is made.)

• To the participants: What is something that the case manager did well?
• To the participants: What is something that the case manager could have improved upon?
After each of the role plays has been completed, bring the group back together. Ask the following
questions for discussion:
• How was it to use the Motivational Interviewing techniques?
• What was different about using Motivational Interviewing compared to Cognitive Beahvioral Therapy
or another skill you are use to doing?`
• What about Motivational Interviewing made the skills you employed easier or where they harder?

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Case Example
20 minutes
Identify previous case and present scenario where the client is at the action stage. Give directions to case
manager to use Motivational Interviewing with a client who is in the action stage of change: This is the
stage where the client is actually making the change. One volunteer will play the case manager, as before,
and the other will role play the client in action stage.
In this case, the audience can provide the case manager with suggestions of questions to ask next. After
5 – 10 minutes, bring the group back together to address the following questions:
• How was it to use the Motivational Interviewing techniques?
• What was different about using Motivational Interviewing compared to Cognitive Beahvioral Therapy
or another skill you are use to doing?`
• What about Motivational Interviewing made the skills you employed easier or where they harder?

Intake, Assessment, and Forms

Figure#1. Process of a Case Manager

LISTEN

- Case manager helps the client to feel comfortable and builds rapport through empathy

CONVERSATION

- Conversation about client's needs, strengths, and supports

- Motivational Interviewing

INFORMED CONSENT

- Case Manager is clear about why they need the information they do, who can access it,
how it can help plan care

BIO-PSYCHOSOCIAL FOCUS

- Conversation about client's needs, strengths, and supports

- Motivational Interviewing

CLIENT'S PRIORITIES

- Keep client's own assessment of their care needs central

CLIENT'S AND CM AGREE NEEDS

- Case manager's observations & risk assessment

- Assessment
- Gather collateral information
- Clear, realistic, achievable goals and solutions

How to ask intake questions

Ask case managers for examples of techniques that make asking new clients questions easier. If there are
positive responses, write these down on flip chart. When interviewing a client, it is important to make them
as comfortable as possible. If a case manager is comfortable with the questions they are asking, the client
will also be more comfortable.

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asking questions, do not ask one after the other in rapid succession; ask them integrated into conversation.
Making it a more natural dialogue can also help the client to relax and feel more open with you.

Activity#2. Group Exercise-Changes

Ask case managers to get into pairs. One person will act as the client first; one will be the case manager
conducting the intake.
The person acting as the client will either make up a client or choose a case they have been working
with. If a real client is chosen, the name and identifying information cannot be given in order to respect
confidentiality.
The person acting as the case manager will conduct an intake with the ‘client’ by practicing skills to build
rapport and conduct an interview.
After 10 minutes participants switch roles and conduct the same activity.
After each case manager has practiced for 10 minutes, the group will come back together for processing.
Questions for discussion:
Did the exercise feel any different than what the case managers normally do?
What was challenging?
What felt like a good change?
Did you notice a difference with the client?

Forms (to be given by the Jordan team representatives at time of the training)
Confidentiality Form [MH]
The case manager must read each section of the form to the client to ensure full comprehension of its
contents. At the end of each section, the case manager should answer any questions the client may have.
Once the client has full comprehension of the Confidentiality Form, and agrees to receive treatment, the
client must sign their name to it in the appropriately marked areas.

Notification of Discharge for Noncompliance [MH]

The case manager must read the statement to the client and explain that if the client misses appointments
for three months, or the case manager is unable to contact the client, their case will be closed. The case
manager must ensure that the client fully understands the contents of this notification.

Client Demographic Form [MH]

The client is responsible for filling out this form prior to meeting a case manager. At intake, the client will
deliver the form to the case manager, whereby the case manager should ask if the client has any questions
about it.

Consent for Release of Confidential Information

This form is completed at intake for all clients, allowing case managers to share information outside of the
immediate IMC or UNHCR treatment team. The form identifies what information will be disclosed and to
whom it will be made available. The form facilitates the sharing of information between projects and

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contracted providers within the broader IMC setting (for example, IMC Mental Health and General
Practitioner, or between IMC Mental Health Team and IMC/UNHCR Protection Team).

*Note: This form needs to be filled out each time information is required to be shared with
another agency, i.e. on referral.

Notes on Intake and Assessment

The File Cover Sheet is included in the client’s file (this applies to both Mental Health and Protection case
management. There is a File Cover Sheet for each case.)
The Intake Checklist is filled in by the team and included in the client’s case file, with forms 1-4. For all
forms, if the client is below the age of 18, their guardian must sign the form as well as the child/adolescent.
Usually the intake and biopsychosocial assessment are completed in same session, however, only when
this is appropriate for the client’s situation (exceptions would be where a client needs urgent intervention).
The Biopsychosocial Assessment Form must be completed within 14 days of intake, and it is updated
annually if the client is still receiving IMC services.

Mental Health Bio-psychosocial Assessment Process and Forms

Comprehensive Biopsychosocial Assessment [MH]
Questions regarding demographic data should be addressed prior. The Best Interest Assessment (BIA) is
covered in the Protection module but items are very similar to this assessment.
Below is a cheat sheet on how to help your client and know what things to look for and potential treatment
modalities.

POSSIBLE TREATMENT
LEVELS OF FUNCTIONING TREATMENT GOALS FOCUS OF TREATMENT
MODALITIES

Didactic/educational Groups
1. Patient demonstrates Increase: • Knowledge
Self efficacy Community/mosques
adaptive functioning with • Understanding
Education Therapeutic classes/groups focused
minimal to-no • Problems Solving
Prevention on developmental issues
symptomology. • Choices/Alternatives
recommended reading.

Decrease symptomology
Individual therapy
2. Patient demonstrates mild Self care
Conjoint therapy
to-moderate symptomology Cognitive restricting Improve coping
Family therapy
which interferes with Behavior Modification Improve problem solving
Group therapy dealing with specific
adaptive functioning. and management of life
issues and/or long term support.
stressors

Stabilization
Daily activity schedule Urgent care
3. Patient demonstrates Productive/pleasurable Intensive outpatient (OP) Reinitiate OP
moderate symptomology Improve daily functioning and activities. Symptom treatment with possible increased
warranting higher level of self-management management. frequency. Medication evaluation/
care Development and monitoring. Therapeutic/educational
utilization of social groups, case management
supports

Increased OP therapy contact

Stabilization, daily activity emergency or urgent care services.
schedule productive/ Intensive OP re-evaluation for acute13
4. Patient demonstrates severe
pleasurable activities intervention. Inpatient treatment,
symptomology Danger to self Monitor and provide safe
Symptom management. safety maintained in structural/
Danger to others. Grave environment
Development and monitored setting with adequate
 Stabilization
Daily activity schedule Urgent care
3. Patient demonstrates Productive/pleasurable Intensive outpatient (OP) Reinitiate OP
moderate symptomology Improve daily functioning and activities. Symptom treatment with possible increased
warranting higher level of self-management management. frequency. Medication evaluation/
care Development and monitoring. Therapeutic/educational
utilization of social groups, case management
supports

Increased OP therapy contact

Stabilization, daily activity emergency or urgent care services.
schedule productive/ Intensive OP re-evaluation for acute
4. Patient demonstrates severe
pleasurable activities intervention. Inpatient treatment,
symptomology Danger to self Monitor and provide safe
Symptom management. safety maintained in structural/
Danger to others. Grave environment
Development and monitored setting with adequate
disability
utilization of social social support. Home health
supports. intervention. Reinitiate individual
treatment when adequately stabilized.

Stabilization Increased OP therapy contact, Urgent

5. Patient demonstrating acute Provide safe environment and Decreased symptomology Care. Intensive OP. Support group,
symptomology rapid stabilization Psychopharmacology medication monitoring, case
Monitoring management.

Inpatient treatment, urgent care,

6. Patient demonstrating acute Provide safe environment partial hospitalization, intensive OP,
Psychopharmacology
symptomology with difficulty Protection of client individual therapy, support group,
Monitoring
stabilizing Protection of others medication monitoring, case
management.

Section A: Assessment of a client’s personal, family, medical and social history

Informants are all the people who have been interviewed regarding the client’s case. This will usually
include family, but could include staff from other organizations or agencies that may have referred this
client. It is important to identify who is involved with the client, to document the information gathered, and
to direct case managers to potential informants or references in the future. In this section, case managers
should list everyone with whom they have spoken, either in person during a clinic visit or home visit, or on
the phone; include the person’s relation to the client.
Review of Collateral Information: In this section, case managers include additional information about
a client, specifically, additional documentation. Generate a brainstorming discussion, writing the examples
of what additional documentation could be included on the flip chart. Include the following examples at
the end of the discussion if they have not been mentioned:
• If client is a child, a report from their school or teacher
• Report cards from school
• Report of benefits received if client receives assistance from another agency/organization
• UNHCR registration, if applicable
Following this discussion, remind case managers to document the name of the report and its listed date.
Having this information helps to ensure that comprehensive services and better care are provided.
Identifying Data: This section aims to establish guidelines for identifying and compiling initial information
about the client. The name and age of the client must always be recorded. If it would be considered rude
to ask the client their age, or if client does not know their age, ask the date of birth and calculate age
accordingly. Also include a brief description of client’s appearance and presentation.
Discussion: Ask case managers what is included in the description of a client’s appearance and
presentation? Record answers/suggestions on the flip chart. Be sure to include:

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 • Appearance: How the client is dressed, and whether there is anything remarkable about it.
• Presentation: Overall presentation, whether they are distressed, voice inflection, general wellbeing.
When writing this section, try to write just the facts and observations rather than personal opinion or
judgment. For example, rather than saying ‘client is dirty and smelly,’ try to rephrase as, ‘client appears
disheveled may not be maintaining personal hygiene.’ This makes it easier for another person to make an
assessment as well.

Activity#3. Initial Assessment Exercise

Ask case managers to separate into pairs. Have each case manager think of a client, and without
giving any identifying information, give them five minutes to write a brief description of their client’s
appearance and presentation.
When all case managers have finished, ask them to turn to their partners and have the partner read
the description.

Presenting Problem: This part of the assessment will be conducted using feedback from the client.
Report why the client is seeking care using their own words. For example, if client says they are seeking
care because they have been feeling sad, report that the presenting problem is sadness.

Activity#4. Presneting Problem

Discussion
Why is it important to understand the presenting problem in client’s own words?
Make sure one of the reasons mentioned (can be by facilitator) is: to give the client a voice in their
care.
(HINT) Repeat these words back to the client to make sure they know you understand where they
are coming from.
Diagnosis: This section is to be filled out by psychiatrist. Space is provided to report an updated diagnosis
if applicable. If the client at any point receives a new diagnosis, do not change the original diagnosis, but
record the new one on the right. The psychiatrist may see the client at the initial intake and assessment
session, however, it is more common for the psychiatrist appointment to happen at a later time; in which
case the case manager goes back to check that this section of the Comprehensive Biopsychosocial
Assessment Form is filled in before progressing to care planning.
Medical History/Medication:
If there is any indication of current suicidal or homicidal ideation the person must be referred for risk
assessment by a qualified mental health clinician.

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Information gathered for this section will come from the interview with the client and any additional
documentation. IMC clients are routinely referred for a medical check-up when they come to IMC, so
case managers will have information from the general practitioner at the time they are conducting the
comprehensive assessment.
Case managers should use the interviewing skills gained in the previous module, as medical history can
be sensitive. Ask the client what injuries they have sustained, any surgeries, major illnesses, and significant
prenatal or childhood events. Also ask about allergies and current medications.

Activity#5. Medical Assessment Exercise

Exercise
Separate the case managers into pairs in preparation for taking a medical history. Ask one case
manager to role play a client and the other to role play the case manager. The role for the volunteer
playing the client is to invent a medical history.
The ‘case manager’ will interview client. After 5-10 minutes, case managers will reverse roles. After
each case manager has had the opportunity to conduct an interview, the group will discuss the
results.
HINT: Whenever there are any doubts, stop the interview and ask a nurse or a supervisor for
guidance.
Discussion:
How did it feel to conduct the medical history?
When you were the client, how did it feel to be asked personal questions?
What interviewing skills were important to keep in mind? Why?

Family History: Information for this section will come from an interview with the client and additional
documents reported in the collateral information section. Just as with medical history, conducting this
interview requires the use of interviewing skills learned in the previous session. This information may be
extremely sensitive and it may be necessary to remind the client about confidentiality. Topics include:
substance abuse history, incarcerations, family violence, abuse, parenting style, marital or sibling discord,
how the family has been involved in client’s behavior, or any other issues deemed significant by the client.
Ask also about the current family. Ask the client about their marital status, persons living in client’s
household, children, and any other issue the client deems significant. Also ask about the family history of
mental health issues.

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Activity#6. Discussion
What are some ways you could ask a client about this information while being respectful and
maintaining rapport?
Record responses on flip chart paper. Ask for a variety of ideas. Solicit suggestions from participatns.
At the end of the discussion, ask why it is important to ask about these topics in a sensitive manner.

History of Client Victimization/Trauma, History of Sexual or Physical Aggression by Client,

History of Self-Harming Behaviors by Client: Just as for the previous sections, the information
solicited for these parts of the form is very sensitive. Case managers need to make the client as
comfortable as possible and to increase the likelihood of obtaining an accurate report.

Activity#7. Techniques for Acute Stress Disorder (ASD) or Postruamatic Stress Disorder
As humans, we have various types of memory. We have short-term memory (items remembered
quickly, such as a telephone number, and then those lost just as quickly), longer-term memory
(permanently stored information) explicit or declarative memory (facts, concepts, and ideas, including
your ability to recall chaotic events in a cohesive way), and implicit memories.
Some ways we can look at exceptional events, trauma or ASD, is by organizing them into three
catagories:
1)Pre-event Factors
2)Event Factors
3)Post-event Factors
Pre-event Factors: Although there are situations in which exposure to trauma is so great that these
factors are less influential (e.g., surviving a major bombing in which nearly everyone dies), certain
pretrauma factors often influence how a person reacts to exceptional events. Among them are the
following:
- previous exposure to severe adverse life events or childhood victimization, including neglect,
emotional abuse, sexual abuse, physical abuse, or witnessing abuse;
- earlier depression or anxiety that is not merely situational and that impacts brain chemistry;
- ineffective coping skills;
- family instability, including a history of psychiatric disorder, numerous childhood seperations
economic problems, or family violence;
- multiple early losses of people possessions, home;
- gender: women have been shown to be twice as likely as men to develop Post Traumatic Stress
Disorder (PTSD) at some time in their lives.
Event Factors: factors related to the victim during the event that contribute to the possibility of developing
PTSD. These may include:
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 - geographic nearness to the event;
- level of exposure to the event: greater exposure leads to a greater likelihood of developing PTSD;
- the event’s meaning or significance to the individual;
- age: being young at the time of the event;
- being a victim of multiple of traumatic incidents;
- duration of the trauma;
- the existence of an ongoing threat that the trauma will continue (e.g., war).
Post-event Factors. This is the final category including risk factors that existed after the event(s), which
may include.
- the absence of good social support;
- not being able to do something about what happened – feeling helpless;
- self-neglect;
- developing ASD (acute stress disorder). ASD occurs in a certain percentatge of people who
experience exceptional events;
- having an immediate reaction (during the traumatic event or shortly after) that includes
physiological arousal (high blood pressure, a startle reaction) and avoidant or numbing symptoms. 13
Important factors that may help coping is the following:
1. Expressed, demonstrated motivation to cope
2. Optimistic attitude
3. An active coping style and success in resolving other crises.
Individual Exercise: My Ability to Cope
Check those of the following statements that you belive apply to you.
___I like to be with people
___I am open to new experiences.
___I am conscientious in the work that I do (I follow through)
___I am an agreeable person
___I believe that my source of personal power lies within me
___I am confident in my own abilities to cope with situations
___I try to find meaning in what happens to me
___I try to breake down bad situations into manageable parts I can handle
___I am motivated to solve the problems that occur in my life
___I am generally an optimistic person - I see things more positiviely than negatively
___I take control in situations whenever possible, or at least try to take control
___I like a good challenge and I rise to the occasion

18 13 Friedman,M.J. 2000 Post-Traumatic Stress Disorder: The Latest Assessment and Treatment Strategies. Kansas City, Mo.: Compact Clinicals.
 ___I am committed to overcoming the bad things I have experienced in life
___I have a good social support network - there are people I can turn to
___I understand my life’s circumstances and what I can and cannot do about them
___I have faith
___I have a good sense of humor
___I have a sense of hope
___I like to try new things or look at things in new ways
___I am open to how others feel
___I am an action-oriented person - I would rather do something than sit back and let it be done to
me.
___I actively try to structure my own life and make plans

What do you observe about yourself frome reading the above statements? Reflect on how you responded
and why?

History of Previous Treatment and Results: It is important to understand what treatment the client has
previously received. This helps the case managers to know if there is some type of treatment that works
well for the client, or if there is some type of treatment that would be better to avoid. A Case manager
should ask the client if they have previously sought treatment for the issue that brought them to seek
services and if so, when.
Client’s & Family’s Perception of Client’s Current Need for Services: This section should only reflect
the ideas and opinions of the client and their family. Ask the client what kind of services they believe
are necessary, and why. What do they hope to get from working with case manager? Case managers
should be sure to ask this question in a way which affirms that they understand that the client’s problem
is important. If the family does not come to the appointment with the client, case managers should record
the efforts that have been made to contact them. It is very important to gather as much information as
possible when working with a client.
ID of Client’s & Family’s Strengths & Resources: This section is used to record all of the resources
available to the client. This can include social supports, religion, education level, personal supports, cultural
identity, employment, spirituality, etc. While some of these may be evident through the intake interview
or in speaking with family members of the client, others may need to be asked about more directly. For
example, if the client does not mention their education level, an appropriate question to ask is: “How many
years have you had in school?” Or, “Up to what year were you in school?” Asking these questions to fill in
the gaps will help the entire team have a more complete picture of the client.
Current Mental Status: This section will be completed with a psychiatrist. Together, the case manager
and psychiatrist will check each of the qualities that apply to the client.
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Some background on Mental Status Exam:
• MSE is a systematic appraisal of the appearance, behaviour, mental functioning and overall
demeanor of a person. In some ways it reflects a "snapshot" of a person's psychological functioning
at a given point in time.
• A MSE is an important component of the assessment of a patient.
• Most of us intuitively perform many parts of a MSE every time we interact with or observe others.
• Observations of person's mental state are important in determining a person's capacity to function,
and whether psychiatric follow-up is required.
• Judgements about mental state should always consider the developmental level of the person and
age-appropriateness of the noted behaviour(s).

** Facilitator; go through the MSE ensuring that each item is described fully on the form. Start with
‘dysphoric’ in ‘Mood/Affect’. Ask for a volunteer to explain what each word means. If no one knows what
one of the words means, ensure that it is explained in a way that can be understood by everyone. Check
for comprehension following the explanation. Go through this section slowly, as it is essential that all of the
case managers understand this vocabulary thoroughly.

Once explanation is given have the case managagers review by writing their definitions on a blank form,
these will be turned in, those that are blank or completed incorrectly will be handed back ito the participant
and through positive reinforcement you will guide the participant until they understand what each term
means. This will support and assist them when talking with clients confidently, speaking with the psychatirst
and in treatment team meetings. Again the MSE will be completed by a psychiatrist but it is important for
the CM to provide guidance on what should go there and be able to feel comfortable asking questions if
something seems out of place.

Section B: Psychosocial Evaluation of Client’s Status and Needs

Start with Psychological Functioning. Under this category, case managers will include information to
provide insight into the client’s psychological functioning. Facilitator can have the following questions on
flip chart paper to guide the discussion:
• How is client coping with the problem?
• What coping strategies are being used?
• Are there disturbances in judgment?
• Are the consequences of behavior understood?
• Is there insight?

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The first thing to assess is the client’s coping strategies that they use to deal with the problem. The client
may not be able to specify what their coping strategies are, so case managers will need to ask questions
in a different way than they are phrased here. These are some of the questions that need to be answered:
• How is the client coping with the problem that led them to seek services?
• What coping strategies are they using?
• Are there any disturbances in the client’s judgment?
• Does the client understand the consequences of their behavior, and to what degree?
• Does the client have insight into their difficulties, or are there impairments (mild, moderate, severe)?
Activity Discussion
Insight & Judgement

Insight and judgement is particularly important in triaging psychiatric presentations and making decisions
about safety.
Insight:
• acknowledgement of a possible mental health problem
• understanding of possible treatment options and ability to comply with these
• ability to identify potentially pathological events (e.g. hallucinations, suicidal impulses)
Judgement:
• refers to a person's problem-solving ability in a more general sense

Brainstorm: what questions case managers can ask to gather the necessary information. Explain
that only asking the questions provided during the training may not be appropriate because clients
may not understand the technical language. How can case managers then solicit this information?
Elicit a few questions for each category – e.g. 3-4 sample questions to determine coping strategies,
to determine judgment, and to determine insight.

Intellectual Functioning: This section of the psychosocial evaluation assesses the client’s intelligence,
ability to function cognitively, and their verbal ability.
While discussing intellectual functioning, refer to the flip chart paper with the following questions and
ensure that each is clear:
• What is the intelligence level of the client?
• How strong is their memory?
• Do their thoughts flow logically?
• Are their thoughts organized or disorganized?
• Is client coherent?
• Does the client have hallucinations or delusions?
• Does the client have any grandiose or bizarre thoughts? 21
Activity#8. Discussion on Intellecutal Functioning
During discussion of these questions, ensure that the technical language and definitions are understood.
Following this discussion, ask case managers how they will assess client with regards to intellectual
functioning.
Ask: How will you be able to assess a client’s intelligence level? Ask the ‘how’ question for each of the
questions on the flip chart paper.

Developmental Functioning: This section of the psychosocial evaluation assesses the client’s emotional,
physical, verbal, and cognitive function in relation to actual age. Is client currently functioning at a similar
level to other people of the same age within their cultural or ethnic group? It is equally important to gain
a history of the client’s early development and their current development. Ask the client if there were
changes in their development preceding current symptoms. This history can help to show the progression
of the symptoms and can provide the case manager with more information.
To help ensure main categories for childrend are covered see the following tip:

C cultural/gender issues coping mechanism conflicts in marital relationships

H hyperactivity (ADHD) health issues (chronic/acute)
I information release for all professionals interactiong with child/adolescents injuries, head trauma
(recent fall/physical trauma) identity issues
Intellectual function
L learning disabilities, learning styles (autitory, visual…) low self-esteem
limitations (physical, mental, psychological, parental/family…)
D drug abuse
defiant and oppositional behaviors
deficient mental capcity
R relationship issues(family, peers, educators, other significant people in child’s life)
resources and resourcefulness
religious/spiritual beliefs
E emotional disturbances and management (emotional/psychological functioning)
educational issues (academic performance, truancy, compliance with rules) experimenting
sexually/ fears or concerns/promiscuity
expectations of life and life goals
empathy and understanding of others
eye and ears (verify that hearing and vision have been checked)
N nutrition/eating disorders
neglect or other issues

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Social Functioning: This section of the psychosocial assessment aims to gather information about the
client’s social relationships and interactions. How are their relationships with others? Ask about relationships
with family members as well as relationships with friends. How are the client’s social skills? This can be
assessed during the interview and also through further questioning. For example: “How comfortable do
you feel in a group?” “How stressful is it for you to interact with family members/friends/others?” “Is it easy
or difficult for you to interact with other people?” The information needed for this section can be obtained
by asking questions such as these.

Substance Abuse: To begin with, explain to the client that the following questions are asked to all people
who seek services. Ask the client how often they drink alcohol or uses controlled substances (drugs). If
the client says they never drink or use substances, case manager can proceed to the next category. If the
client says they do drink or use controlled substances, the following questions need to be answered to
determine if substance abuse exists:
• Is substance use interfering with the client’s daily functioning?
• Is the client attempting to self-medicate?
• Is a family member’s substance abuse a factor in treating the client?
• Is there repeated substance use in situations in which it is physically hazardous?
• Are there recurrent substance-related legal problems?
• Is there continued substance use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of the substance?
• Has the client developed an increased tolerance for the substance?
• Does the client experience withdrawal symptoms from the substance?

If the answer to one or more of these questions is ‘yes,’ the client is suffering from substance abuse.
It is important to evaluate each of these questions and mark the specific information gathered on the
assessment form.

Spiritual/Religious: This section is used to gather information about client’s personal concept of faith
or religious affiliation, parental wishes, and family background. It is important to gather this information
because spirituality and religion can be strengths to be used in a more client-centered treatment plan. It is
also important to assess the client’s spirituality and religion as well as the spiritual/religious background of
their family to determine if there is a conflict.

Cultural: It is important to gather cultural information about the client as it may help to guide the treatment
plan. What is the client’s ethnic identification? What is the client’s heritage?

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How has his/her race shaped client’s background and upbringing? What are the wishes of client’s parents
or family regarding how cultural needs are to be met in treatment? This information needs to be gathered
directly from the client because it is his/her views that are relevant for the assessment.

Activity#9. Group Discussion

How can this information be gathered sensitively? Do you foresee any difficulties in gathering this
information?

Leisure and Recreation: What does the client do for fun? Are they involved in any activities outside
the home? Does the client participate in sports or have any hobbies? This section should be relatively
straightforward and easy for the client to answer.

Section C: Evaluation of High Risk Behaviors or Potential for Such

During the assessment, it is important to ask client if they have any plan or intent to harm themselves or
others. This can be assessed by asking the following questions:
• Have you been feeling very sad lately?
• Have you had any thoughts about hurting yourself or someone else?
• In the last 60 days have you had any thoughts that feel troublesome?
• Has something very stressful happened in the last 60 days?
• Have you lost interest in things that have previously been enjoyable?
• Have you experienced a loss of energy?
• Have you had feelings of worthlessness?
• Have you had recurrent thoughts of death?
• Do you have a plan for hurting yourself?

Client Risk Assessment

A Client Risk Assessment form is completed for every client at the time of biopsychosocial assessment.
Completion of a risk assessment is a precursor to care planning. The case manager and the client complete
the assessment together, involving other family members and caregivers only with the knowledge and
consent of the client. Where a client responds “yes” to any of the risk assessment questions under any of
the categories (risk to self, risk to others, and risk by others) the case manager needs to involve a senior
clinician immediately to put together a safety plan as part of the care planning process.

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Section D: Issues Affecting Discharge
This section addresses the factors that are needed for a successful discharge and those which could
hinder it. It is important to identify potential inhibitors with the client as well. What does the client identify
as potential problems? Have the case managers brainstorm/provide ideas of what could be a potential
barrier.
Examples:
• Transportation difficulties
• Lack of funds
• Non-compliance
• Abuse/neglect in the home
• Lack of family involvement

After discussing potential barriers to a successful discharge, it is also important to note what is needed or
required for a successful discharge to occur. It is important to include the client in this discussion, as they
will know what they need in order to complete treatment successfully.

Exercise: Group Discussion

Lead a group discussion in the same manner as the previous activity, asking case managers to
provide examples of potential requirements that a client may identify.
Examples:
• Ability to arrive to the clinic
• Low cost of medication
• Involvement of family members
• Support from family members
• Feeling welcome in the clinic

Section E: Writer’s Impressions

This section is not a repetition of the information already provided in the assessment. This is the space
for the case manager to apply the knowledge gained to the clinical presentation of the client. Based on
the client’s diagnosis and background information, what are the treatment recommendations? What are
the client’s service needs and how much structure will be necessary in treatment? Is there a need for
monitoring the client? Incorporate client’s strengths (whether internal or external) into treatment while
being mindful of unique, individual challenges client faces.

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Activity#10. Completing an Assessment
Provide case managers with an example assessment. Give them 5-10 minutes to read through the
assessment, then explain that they are to individually complete a ‘writer’s impression’ section with
the information provided.
State that it is not expected to be a perfect section since the assessment is only an example and
case managers have not actually met the client. Give case managers 10 minutes to write the ‘writer’s
impressions’ while monitoring progress and providing feedback.
Once each case manager has finished, case managers will pair up and have the partner read and
provide feedback on the ‘writer’s impressions.’
Discuss

Mental Health Care Planning Process and Forms

Care Planning Process

ASSESSMENT

- Care Planning begins at assessment

- Strengths and Support
- Clear goals and objectives from Assessment

CREATE INITIAL CARE PLAN

- Base plan on biopsychosocial assessment, goals and objectives, and client functioning scale

INCLUDE CLIENT IN PLANNING

- Ask client: If problem were solved what would be different?

- What would be the signs that things were different?
- What needs to happen for this difference to occur?

PRESENT CARE PLAN TO TEAM

- Case Manager presents initial care plan to Care Team - reflects client goals and all assessment information
- Recommendations are refined and approved

CLIENT AGREEMENT

- Client agreement to care plan is sought

- Case Manager co-ordinates care and interventions and treatments on client's behalf

MONITORING

- Case Manager ensures services have been delivered according to the plan and client satisfaction
- Case Manager checks how client is progressing
- Case Manager + client + care team make changes to the plan as needed

Care Planning starts at intake. At intake and during assessment, the client and the case manager agree on
the clients’ concerns, needs and priorities. Goals and objectives and interventions begin to be formulated
during the assessment process. The client and case manager work out a proposed Initial Care Plan based
on the information in the assessment, the goals and objectives, and the client functioning scale.

26
The case manager and the entire care team discuss the Initial Care Plan. The case manager ensures that
the team understands and hears the clients’ concerns, goals, and objectives in the way that they were
communicated to the case manager. The case manager seeks the input and advice of the respective
specialist members of the team on the proposed Initial Care Plan and follows up accordingly.
Sometimes, at this stage, the case manager may need to go back to the client to get more information or
discuss ideas and recommendations made by the care team.

At the Care Plan Meeting (Case Presentation) the Initial Care Plan is agreed and approved (which means
signed by the senior clinicians). More detail on the Care Plan Meeting is in Module 10.

Including the Client in Care Planning

A good care plan is tailored to the individual needs of the client. It directly addresses the problem or issue
that led them to seek services from and uses interventions that are appropriate for their lifestyle. In order
to create the treatment plan, the biopsychosocial assessment and client functioning scale need to be
completed first. Information will be taken from these two documents and combined with feedback from
the client in order to create the treatment plan.

Before creating a care plan, it is important to ask the client: “If the problem that brought you in today were
solved, what would be different?” The client’s answer to this question can provide the case manager with
information on the client’s goals. The things that the client would like to have different in his/her life are his/
her goals.

After asking what would be different, the case manager needs to ask the client how they will know that
the difference is occurring. What will be the signs telling them that things are different? What are the small
steps along the way that are necessary for this difference to occur? For example, if the client will know
that things will be better when them has a job, what needs to happen first for the client to get a job? First,
they need to have an interview. What needs to happen before they can get an interview? They need to
ask about available jobs or submit their resume to an employer. The small steps that need to happen to
achieve the big difference are the objectives in the treatment plan.

After asking about the small steps, it is then important to ask the client how they think these small steps
could be accomplished. Every individual is the expert on their life and will be able to come up with the most
feasible and realistic solutions for themselves. To continue with the previous example, what does the
client think they could do to get an interview? Perhaps the client would say that they could ask different
employers about job opportunities, make a resume, and then turn in the resume to an employer.

27
These very small steps that the client could take become part of the intervention.

Activity#11. Exercise/Role Play

Ask case managers to partner up and choose who will first role play the client and who will role play
the case manager.
The volunteer role playing the client will have to invent a scenario for seeking treatment.
The case manager will then conduct the discussion as mentioned previously. Remind case managers
to take notes. Ensure the following questions are asked:
• If the problems that brought you into the clinic were solved, what would be different?
• What will you notice that will tell you that things are different?
• What are the small steps along the way that need to happen for this difference to occur?
• What can you do to make these small steps occur?
After 10-15 minutes of discussion, case managers will switch roles. The case manager role playing
the client will create a new scenario and the case manager will start over asking these questions.
After each case manager has had 10-15 minutes to practice the discussion, tell case managers
that they will practice writing a treatment plan from the information they obtained from the interview.
They should have a few goals that are derived from the differences the clients want to see in their
lives, be able to derive the objectives from the small steps the clients mentioned, and should have
the interventions from the ideas the clients gave stating what they could do to make the small steps
occur. Give case managers 15 minutes to create the sample treatment plan.
Bring everyone back together as a group. Process with the following questions:
• What did you notice that was different about conducting a session in this way?
• How was it to ask the clients for the answers instead of telling them what to do?
• For the clients, how was it to be asked these questions?
• How was it to be asked for input in treatment?
• Are there any questions about the activity or about how it ties into the treatment plan?
• How was it to create a treatment plan from the interview with the client?
After the discussion, have case managers get back into their original pairs.
Clients will provide feedback on the sample treatment plan since they are based on the original
discussion. Have clients include at least one thing that was done well and one thing that could be
improved.
Give case managers time to read over the treatment plans and five minutes for each case manager
to provide feedback on the plans.
We are going to discuss how to use the biopsychosocial assessment and client functioning scale to
aid in the creation of the treatment plan.

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Biopsychosocial Assessment: One important aspect of the biopsychosocial assessment is the section
that identifies the client’s strengths and resources, which must be utilized by the case manager. The
characteristics and supports that are listed in the area are good tools to use when creating an objective
or intervention. When creating the intervention, it is helpful to capitalize upon the strengths and resources
that the client already has because it will make the intervention easier and more client-centered.

Another important part of the biopsychosocial assessment to consider is the psychosocial evaluation.
It contains information specific to the client that needs to be taken into consideration when designing
appropriate goals, objectives, and interventions. For example, if the client experiences delays in
development, the intervention needs to be developmentally appropriate. The client’s cultural identification
and spirituality also needs to be considered while creating the treatment plan. Be sure that the intervention
is culturally appropriate and if the case manager is not sure, ask the client. Many people turn to spirituality
for strength, so incorporating spirituality into the treatment plan can also help to make it more client-
centered. Finally, the leisure and recreation section is a good place to start if the client is having trouble
coming up with activities as part of an intervention. What is the client already doing? Is there a similar
activity they could try? Could they increase the frequency of a certain activity or hobby? The information
in this assessment form is available to help the team create a more individualized treatment plan to help
client to get better faster.

Client Functioning Scale: The client functioning scale is a form that is used to assess the client’s level of
functioning in various tasks. It is best to complete this form with input from the client, but in some instances
this may be impossible. If the client comes to IMC services with acute symptomology and a lack of insight,
case managers may need to complete the form based on the assessment done of the client combined
with feedback obtained from family or friends of the client. The first box assesses physical functioning.
Functioning is assessed in relation to others the same age as the client. The first task to be assessed is
grooming. Does the client have difficulty grooming or dressing themselves? If there is no difficulty, mark the
‘0.’ If there is little difficulty, mark ‘1,’ if there is moderate difficulty mark ‘2,’ a lot of difficulty mark ‘3,’ and
if the client often cannot complete the task mark ‘4.’ If the case manager has marked a 3 or a 4, then this
area has been identified as a problem area. The final column, ‘cause of difficulty’ is only completed for the
tasks or activities that have been identified as problem areas. If grooming is a problem area, it is necessary
to identify the source of this difficulty. Is the cause cognitive, emotional, behavioral, psychosomatic, related
to physical illness or disability, or from a different source? Explain the cause of difficulty as needed.

29
The next category to be assessed is eating. Is the client able to use utensils appropriately? Are they eating
appropriate foods and eating appropriate amounts? Just as with the previous category, the degree of
difficulty is to be assessed by rating the client on a scale of 0-4. If the client receives a rating of either a 3
or a 4, then the cause of difficulty must be noted.

The final two categories to assess for physical functioning are sleeping and able to care for and manage
possessions. They are assessed in the same manner as the previous two and a cause of difficulty must be
provided for any score of 3 or 4.

Interpersonal Relationships: The first aspect of interpersonal relationships to be assessed is the extent
to which the client accepts contact with others. Next to be assessed is if the client is able to initiate
contact with others, and the third aspect is if the client is able to communicate effectively. Finally, does the
client form and maintain relationships and spend appropriate time with family? All of these aspects will be
assessed on a scale of 0-4; and those categories scoring a 3 or a 4 must have a cause of difficulty listed
to explain the score.

Social Acceptability: Following the assessment of interpersonal relationships, social acceptability will be
assessed. Is the client verbally inappropriate with others? Physically inappropriate with others? Does the
client destroy property or engage in self-harm? Do they show excessive dependency? Does the client take
property from others without permission or perform repetitive behaviors? Each of these aspects of social
acceptability will be rated on a scale of 0-4 and the categories that score a 3 or a 4 must have a cause of
difficulty listed to explain the score.

Daily Skills: After finishing the assessment on social functioning, activities functioning and daily skills will
be assessed. The various aspects of daily skills that will be assessed include household responsibilities,
shopping, handling of personal finances, use of the telephone, use of public transport, use of recreational
time, taking medication, use of medical services, use of community services, and ability to learn new
things. These aspects of daily skills will be assessed just as the skills in the other categories have been
assessed.

Applied Skills: The final category to be assessed in the client functioning scale is activities functioning in
applied skills. Only two aspects of applied skills are assessed, the ability to work with minimal supervision
and the ability to sustain working activity. These skills are assessed and described in the same manner
of the other categories. The client functioning scale provides the team with more specific direction to use
when creating the treatment plan.

30
The items on which the client scored a 1 or a 2 do not need to be included, as the client is already coping
well in these areas. The items on which the client scored a 3 or a 4, however, are areas in which the client
is having more difficulty. These difficulty areas should be addressed somewhere within the treatment plan.
If an outline for the treatment plan has already been made through discussion with the client, the case
manager needs to check to see if these difficulty areas are included anywhere in the treatment plan. If
not, new goals and objectives can be developed to address these areas or additional interventions can be
added to existing objectives to ensure that they are addressed.

Activity#12. Functioning Scale

Provide case managers with sample client functioning scales and biopsychosocial assessments for
two example clients.
Case managers can work individually or in pairs and will use the information from these two forms to
create sample care plans containing goals, objectives, and interventions.
After 20 minutes, tell case managers that they should switch to start working on the treatment plan
for the other client. After 20 more minutes, call case managers back together.
Have case managers find a partner. The partner has to be someone the case manager has not yet
worked with in this activity.
One case manager will review and provide feedback on the treatment plan of the other case manager
– for the feedback, at least one comment should be on something that was done well and one
comment should be on something that can be improved.
After 10 minutes, the other case manager will have 10 minutes to review and provide feedback.
After each case manager has had their sample treatment plan reviewed, call the group back together
and askfor one or two volunteers who would like to present their sample treatment plan to the entire
group. The group will then provide feedback to the case managers who presented the sample care
plans.
Group Feedback:
Which parts of the biopsychosocial assessment are most valuable to use when making the treatment
plan?
How is information from the client functioning scale used in the creation of the treatment plan?

Client Functioning Scale

Scoring Client Quality of Life, Strengths and Needs
Instructions: Circle the number that best describes this person’s typical level of functioning on each item
listed below. Be as accurate as you can. If you are not sure about a certain rating, ask someone who may
know or consult the case record. Mark only one number for each item. Be sure to mark all items.
A score of 2 or less indicates a STRENGTH. A score of 3 or 4 indicates a WEAKNESS.
Scores of 3 and 4 should be addressed through Treatment Goals in the Care Plan.

31
 SOCIAL FUNCTIONING: Interpersonal Relationships

Ask clients to assess their degree of difficulty with these activities compared to how other people their age should be able to complete them.

TASK OR ACTIVITY Degree of difficulty in completing the task CAUSE OF DIFFICULTY

Often
None Little Moderate A lot (Circle and comment as necessary)
cannot do task

a. Mental health related: cognitive

b. Mental health related: emotional
1. ACCEPTS CONTACT WITH
OTHERS: when approached in a c. Mental health related: behavioral
0 1 2 3 4
social context, does not withdraw or d. Mental health related: psychosomatic
turn away
e. Physical illness, injury, or disability
f. Other (please explain): _________________

a. Mental health related: cognitive

b. Mental health related: emotional
2. INITIATES CONTACT WITH
OTHERS: seeks out new c. Mental health related: behavioral
0 1 2 3 4
relationships, meets and socializes d. Mental health related: psychosomatic
with new families
e. Physical illness, injury, or disability
f. Other (please explain): _________________

a. Mental health related: cognitive

b. Mental health related: emotional
3. COMMUNICATES EFFECTIVELY: c. Mental health related: behavioral
speech and gestures are 0 1 2 3 4
comprehensible and to the point d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

a. Mental health related: cognitive

b. Mental health related: emotional
4. FORMS AND MAINTAINS
FRIENDSHIPS: spends time with c. Mental health related: behavioral
0 1 2 3 4
friends, maintains contact with old d. Mental health related: psychosomatic
friends
e. Physical illness, injury, or disability
f. Other (please explain): _________________

a. Mental health related: cognitive

6. SPENDS TIME WITH FAMILY b. Mental health related: emotional
AND FRIENDS: values and
appreciates time with family; spends c. Mental health related: behavioral
0 1 2 3 4
time practicing cultural activities with d. Mental health related: psychosomatic
family members, sharing holidays,
sharing meals e. Physical illness, injury, or disability
f. Other (please explain): _________________

SOCIAL FUNCTIONING: Social Acceptability

Ask clients to assess their degree of difficulty with these activities; compared to how other people their age should be able to complete them.

TASK OR ACTIVITY Degree of difficulty in completing the task CAUSE OF DIFFICULTY

Often
None Little Moderate A lot (Circle and comment as necessary)
cannot do task

1. VERBALLY INAPPROPRIATE a. Mental health related: cognitive

WITH OTHERS: uses socially
b. Mental health related: emotional
inappropriate language, aggressive
language, blaming others, swearing c. Mental health related: behavioral
0 1 2 3 4
unnecessarily, threatening, using d. Mental health related: psychosomatic
language provocatively
e. Physical illness, injury, or disability
f. Other (please explain): _________________

2. PHYSICALLY INAPPROPRIATE a. Mental health related: cognitive

WITH OTHERS: pushes, hits/strikes
32
with hand, fist, or foot, makes
b. Mental health related: emotional

unwanted physical contact, c. Mental health related: behavioral

0 1 2 3 4
including inappropriate sexual d. Mental health related: psychosomatic
1. VERBALLY INAPPROPRIATE a. Mental health related: cognitive
WITH OTHERS: uses socially
b. Mental health related: emotional
inappropriate language, aggressive
language, blaming others, swearing c. Mental health related: behavioral
0 1 2 3 4
unnecessarily, threatening, using d. Mental health related: psychosomatic
language provocatively
e. Physical illness, injury, or disability
f. Other (please explain): _________________

2. PHYSICALLY INAPPROPRIATE a. Mental health related: cognitive

WITH OTHERS: pushes, hits/strikes
b. Mental health related: emotional
with hand, fist, or foot, makes
unwanted physical contact, c. Mental health related: behavioral
0 1 2 3 4
including inappropriate sexual d. Mental health related: psychosomatic
contact
e. Physical illness, injury, or disability
f. Other (please explain): _________________

3. DESTROYS PROPERTY: breaks a. Mental health related: cognitive

items, uses spray paint or other
b. Mental health related: emotional
mechanism to deface property,
intentionally disrespects public or c. Mental health related: behavioral
0 1 2 3 4
personal items d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

4. ENGAGES IN SELF-HARM: a. Mental health related: cognitive

cutting, burning, intentionally
b. Mental health related: emotional
restricting food or water, engages in
self-punishment c. Mental health related: behavioral
0 1 2 3 4
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

5. SHOWS EXCESSIVE a. Mental health related: cognitive

DEPENDENCY: afraid to leave the
b. Mental health related: emotional
house unaccompanied, excessive
crying, clinging to others for comfort c. Mental health related: behavioral
0 1 2 3 4
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

6. TAKES PROPERTY FROM a. Mental health related: cognitive

OTHERS WITHOUT PERMISSION:
b. Mental health related: emotional
does not ask permission or
recognize importance of asking c. Mental health related: behavioral
0 1 2 3 4
others for permission d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

7. PERFORMS REPETITIVE a. Mental health related: cognitive

BEHAVIORS: pacing, rocking,
b. Mental health related: emotional
making noises, having compulsions
to repeat tasks that cannot be c. Mental health related: behavioral
0 1 2 3 4
controlled d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

ACTIVITIES FUNCTIONING: Daily Skills

Ask clients to assess their degree of difficulty with these activities; compared to how other people their age should be able to complete them.

TASK OR ACTIVITY Degree of difficulty in completing the task CAUSE OF DIFFICULTY

Often
None Little Moderate A lot (Circle and comment as necessary)
cannot do task

1. HOUSEHOLD a. Mental health related: cognitive

RESPONSIBILITIES: consider what
b. Mental health related: emotional
is expected for the client, whether it
is providing financial support of the c. Mental health related: behavioral
0 1 2 3 4
household, cleaning, cooking, d. Mental health related: psychosomatic
helping with children
e. Physical illness, injury, or disability
f. Other (please explain): _________________

2. SHOPPING: including selection of a. Mental health related: cognitive

items, choice of stores, payment at
b. Mental health related: emotional
register

0 1 2 3 4
c. Mental health related: behavioral
33
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
1. HOUSEHOLD a. Mental health related: cognitive
RESPONSIBILITIES: consider what
b. Mental health related: emotional
is expected for the client, whether it
is providing financial support of the c. Mental health related: behavioral
0 1 2 3 4
household, cleaning, cooking, d. Mental health related: psychosomatic
helping with children
e. Physical illness, injury, or disability
f. Other (please explain): _________________

2. SHOPPING: including selection of a. Mental health related: cognitive

items, choice of stores, payment at
b. Mental health related: emotional
register
c. Mental health related: behavioral
0 1 2 3 4
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

3. HANDLING OF PERSONAL a. Mental health related: cognitive

FINANCES: including budgeting
b. Mental health related: emotional
resources, paying bills
c. Mental health related: behavioral
0 1 2 3 4
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

4. USE OF TELEPHONE: getting a. Mental health related: cognitive

numbers, dialing, speaking, listening
b. Mental health related: emotional
c. Mental health related: behavioral
0 1 2 3 4
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

5. USE OF PUBLIC TRANSPORT: a. Mental health related: cognitive

selecting route, using timetable,
b. Mental health related: emotional
paying fares, making transfers, using
taxis c. Mental health related: behavioral
0 1 2 3 4
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

6. USE OF RECREATIONALTIME: a. Mental health related: cognitive

praying, watching television,
b. Mental health related: emotional
socializing with friends
c. Mental health related: behavioral
0 1 2 3 4
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

9. TAKINGMEDICATION: a. Mental health related: cognitive

understanding the purpose of
b. Mental health related: emotional
medication, taking as prescribed,
recognizing side effects c. Mental health related: behavioral
0 1 2 3 4
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

10. USE OF MEDICAL SERVICES: a. Mental health related: cognitive

knowing whom to contact, getting
b. Mental health related: emotional
regular health check-ups (as
appropriate for age and gender) c. Mental health related: behavioral
0 1 2 3 4
recognizing medical needs d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

11. USE OF COMMUNITY a. Mental health related: cognitive

SERVICES: knowing who to contact,
b. Mental health related: emotional
how to contact, and when to use
them c. Mental health related: behavioral
0 1 2 3 4
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

12. CAN LEARN NEW THINGS: is a. Mental health related: cognitive

willing and able to learn to do a new
b. Mental health related: emotional
task, skill
c. Mental health related: behavioral
34 0 1 2 3 4
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
11. USE OF COMMUNITY a. Mental health related: cognitive
SERVICES: knowing who to contact,
b. Mental health related: emotional
how to contact, and when to use
them c. Mental health related: behavioral
0 1 2 3 4
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

12. CAN LEARN NEW THINGS: is a. Mental health related: cognitive

willing and able to learn to do a new
b. Mental health related: emotional
task, skill
c. Mental health related: behavioral
0 1 2 3 4
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

ACTIVITIES FUNCTIONING: Applied skills

Ask clients to assess their degree of difficulty with these activities; compared to how other people their age should be able to complete them.

TASK OR ACTIVITY Degree of difficulty in completing the task CAUSE OF DIFFICULTY

Often
None Little Moderate A lot (Circle and comment as necessary)
cannot do task

1. IS ABLE TO WORK WITH a. Mental health related: cognitive

MINIMAL SUPERVISION: makes
b. Mental health related: emotional
appointments on time, can complete
tasks c. Mental health related: behavioral
0 1 2 3 4
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): _________________

2. IS ABLE TO SUSTAIN WORKING a. Mental health related: cognitive

ACTIVITY: not easily distracted, can
b. Mental health related: emotional
complete tasks under stress
c. Mental health related: behavioral
0 1 2 3 4
d. Mental health related: psychosomatic
e. Physical illness, injury, or disability
f. Other (please explain): ______________

Developing Client Goals and Objectives

Goals
Case managers work with clients to develop goals and objectives that are written into their care plan. Case
managers do not make goals for clients without the client’s collaboration. When working with children,
case managers need to note that the parent or parents were involved in decisions around setting goals
and objectives. For an adult, note the fact that the client has participated in determining their goals.
On the assessment and evaluation forms, clients are asked what they see as the main issues to be
resolved and what they expect of services.
Goals are the outcomes you expect to occur as a result of treatment, services, or intervention you have
chosen. Goals are worded in positive ways. The aim is for clients to focus on what will happen, rather than
what will not happen or what might happen; case managers have a role in assisting clients to focus in this
way.
The intention of a goal is to state what will happen as a result of an intervention or service being provided,
e.g. Lina will be able to play co-operatively with the other children.

35
 • A client’s goal is the result of the treatment or intervention
• The client is the subject of the goal
• There is only one condition for your goal
• The goal is written in one sentence
• The goal is written in the positive
Objectives
Goals are often similar for similar populations. Many clients seek help for similar reasons, and therefore,
may have similar goals.
Every goal has objectives. Objectives are concrete, observable, and measurable. Based on the overall
goal, they may be broken down further, into steps towards an objective, which is part of the overall goal.
An objective could be:
• Tariq will talk to at least three other children every day without hitting.
Steps to this could include:
• Tariq will observe the activities without hitting other children.
• Tariq will complete one activity daily without hitting.
• Tariq will participate in an entire day of school without hitting other children.

Goal Development: Looking for Client Strengths

1. Look for community supports in the community for the client and the client’s family. For example:
• Is the client involved in a mosque, club, or recreational program?
• Are there any other social services involved?
• Does the client have a strong circle of friends?
2. What are the religious or cultural beliefs, practices, or values observed by this person, and how does he
or she draw on these for support and comfort?
3. When your client interacts with others, such as staff, family, and pets, what interpersonal skills doe she
or she appear to have?
4. What special abilities or skills does the client possess?
5. If you gave the client a choice as to what they would prefer to do, what would they be most likely to
choose?
6. What hobbies, recreational activities, or talents, does the client pursue? What interests this person?
7. With whom is the client most likely to want to spend time with?
8. Who outside the client’s family has shown interest in this person?
9. If the client has contact with their family, what does the family do together?

36
Concrete, Observable Objectives
Review what you have written. Read what you have written out loud and ask yourself if you will be able to
see or hear the client doing that – for it to be an objective – it needs to be an action that can be observed
or heard.

These are not objectives: The client will gain insight into their problems with their mother, or understand
the importance of substance abuse treatment, or a child will work well with others at school. Instead,
treatment objectives need to be worded in the following manner:
You will know a client has gained some insight into their problems with their mother because he talks
about this insight. The treatment objective would therefore be: The client is able to talk about the problems
they and their mother have.
You may observe that the client understands the importance of substance abuse treatment by the
consistency with which they attend the meetings. The treatment objective would therefore be: The client
will attend substance abuse meetings twice a week.
You can hear a report that the client worked well at school. The treatment objective would therefore be:
The client will receive positive reports from their teacher that they cooperated with the other children on
classroom projects.

Measurable Objectives
State how the objective will be measured, e.g. evidenced by attendance at substance abuse support
group meeting, and give each objective a target date.
Record progress on the objectives and towards the goals in the case notes. Include any new additions or
revisions.

Treatment Interventions
If you give the client an assignment or task that will help them complete one of their objectives, this is
a treatment intervention. Treatment interventions are not goals or objectives. They are what you, the
case manager, are doing to help the client complete an objective or work toward their ultimate goal. For
example, providing information on the times and places where support groups are offered to the client
whose objective is to attend a support group twice a week.

Example Goals - Ahmed

The following is an example of goal, objective, and intervention planning for Ahmed, whose goal is to find
work. Ahmed must review his strengths, and also the “barriers” that impede his ability to reach his goal.
Ahmed has anxiety and depression, two barriers that hold him back from his goal. The short-term objective
(small first step) for Ahmed is to work at a job for 5-10 hours per week. This might seem small, but it would
be a good step for Ahmed to work towards his longer-term goal of going back to work full-time.

37
 Goal “I want to go back to work. I really want a job.”

Goals are what you want to work on in your life, and should
be in the client’s own words.

Barriers Strengths

Barriers are things that stand in the way of the client Strengths are those things that the client is good at;
reaching their goal. their talents, abilities, skills, and also past experiences
!
Ahmed feels nervous and anxious Strong work ethic

filling out applications and inquiring about job positions. History of previous work as a cashier

He has difficulty getting up in the morning, due to severe Good communicator

depression.
Strong connection to peer recovery mentor at health
He needs assistance with filling out paperwork and creating center
a resume.

Table#2. Example of Behavioral Treatment Goal and Objectives

Goal Ahmed wants to find work

Objectives Ahmed will work in paid employment at least 5 hours per week.

Interventions Psychiatrist to meet with Ahmed once monthly for 30 minutes for the next 3 months to
adjust medication and decrease symptoms.

Primary psychologist, or qualified mental health personel, to meet weekly with Ahmed for 45

!
minutes for three months to provide CBT coping strategies (e.g., thought stopping,
visualization, deep breathing) to help manage his symptoms which increase when he is
pursuing job related activities.

Job coach to provide support to Ahmed by helping him work on his resume and job
applications, for 3 months.

Ahmed to participate in Recovery Action Planning group (facilitated by his peer recovery
mentor) bi-weekly to come up with simple, safe, and effective strategies for staying well and
increasing his sense of control over his life and symptoms.

Ahmed to finish his resume in the next 6 weeks, with the assistance of his job coach.

Activity#13. Developing Goals, Objectives, and Interventions

Small Group Exercise
45 mins
Activity: Prepare flip chart paper with the following definitions:
Goal: One thing you want to improve in your life.
Objective: The small step that moves you towards your goal.
Intervention: The actions that you or your supporter will take to help you accomplish your objective
and work towards your goal.

38
 Prepare another flip chart paper with the following list:
• Depression
• Suicide
• Developmental disorder
Go through the definitions on the flip chart paper with the case managers. Explain that a goal is
something that the client would like to achieve. You will get this information from them, but how to
get this information will be discussed in the next session. The goals are generally centered around
what a client wants to get out of treatment. The differences that they would like to see in their life.
The objective is the small step that helps a person move towards their goal. When someone is
working towards a goal, it is often easier to divide up the work that it takes to get there into smaller
steps that are easier to take.
The intervention is the action that will be taken to achieve the objective. For the purposes of a
treatment plan, the action will be taken by the client, the clinic team, or the family or support of the
client. The intervention can be something that the client will do on their own, it can be therapeutic, or
it can be something like joining a structure.
Tell case managers that they practice creating care plans. They do not have to have a specific client
in mind, but can make one up if they like.
Display flip chart paper with the disorder list.
Inform case managers that they will create a sample care plan for each of these disorders. Each care
plan must have two goals with two objectives each. Each objective must also have two interventions.
Case managers will be given 10 minutes to design each care plan (30 minutes in total).
After each 10-minute interval, ask case managers to move on to the next disorder.
After case managers have finished with all three care plans, they will share the care plans in small
groups of 3 – 4 case managers. Each group will be directed by a facilitator. The facilitator can provide
guidance when necessary, but most of the feedback should come from the other case managers.
Be sure that each case manager receives feedback on at least one thing they are doing well and one
thing that could be improved.
Refer to examples below in group discussion to demonstrate care plans.
After the small group discussion, bring the group back together.

Table #3. Example of Behavioral Treatment Goal and Objectives

Goal Lina will play cooperatively with the other children as evidenced by reports from the teacher
on playground duty.

Objectives Lina will be able to engage in one classroom activity daily for two consecutive weeks
without pushing her peers.

Lina will be able to follow her teacher’s directions first time asked for two consecutive
weeks.

!
39
Table #4. Example of Depression Treatment Goal and Objectives

Goal Client will improve coping skills to cope with feelings of sadness.

Objective 1 Client will utilize coping skill two times per week when becoming distressed.

Interventions 1 Teach coping skills – deep breathing, guided imagery.

Psychoeducation – discussing the benefits to using coping skills and when to use them.

Objective 2 Client will practice coping skills every morning for 10 minutes.

Interventions 2 !
Teach coping skills: Progressive muscle relaxation, deep breathing.

Table #5. Example of Suicide Treatment Goal and Objectives

Goal Client will increase feelings of happiness

Objectives Client will engage in an activity that provides (or used to provide pleasure) 15 minutes each
day.

Interventions Daily activity planning

Role Playing (CBT)

!
Table #6. Example of Developmental Disorders Treatment Goal and Objectives

Goal Client will increase positive interactions with family.

Objective 1 Client will share feelings with words twice per week.

Interventions 1 Role playing (CBT)

Modeling (CBT)

Objective 2 Client will walk away from a fight without hurting anyone two times per week.

Intervention 2 !
Role playing (CBT)

Deep breathing (Relaxation Skills)

Objective 3 Client will listen to his/her family at dinner without interrupting once per week.

Intervention 3 Problem solving skills (CBT)

Role playing (CBT)

Emotion Identification (CBT)

Table #7. Example of Depression Treatment Goal and Objectives

Goal Client will improve self esteem

Objective 1 Client will tell herself that she is worth something once per day.

Interventions 1 Cognitive restructuring

Scaling to determine how much the client believes this thought.

Objective 2 Client will spend 45 minutes with someone values her company twice per week.

40
Interventions 2 !
Client will identify a person who they believe values them.

Role play, so client can practice being comfortable with this person.
 Goal Client will improve self esteem

Objective 1 Client will tell herself that she is worth something once per day.

Interventions 1 Cognitive restructuring

Scaling to determine how much the client believes this thought.

Objective 2 Client will spend 45 minutes with someone values her company twice per week.

Interventions 2 !
Client will identify a person who they believe values them.

Role play, so client can practice being comfortable with this person.

Goal Client will increase knowledge, understanding, and control of his/her moods.

Objective 1 Client will calm his/her body when feeling angry once per week.

Interventions 1 Deep breathing (Relaxation skills)

Emotion Identification (CBT)

Emotion Regulation (CBT)

Objective 2 Client will tell a family member when feeling angry three times per week.

Interventions 2 Emotion Identification (CBT)

Role Playing (CBT)

Table #8. Example of Psychosomatic Treatment Goal and Objectives

Goal To determine the cause of the physical pain

Objective 1 Physical exam will be conducted

Interventions 1 An appointment will be scheduled with physician to conduct a comprehensive physical

exam

Activity #14. Care Planning Goals, Objectives, Interventions

Individual exercises
!
Case Vignettes

Case #1
Lina is a 19 year old woman who came to the clinic for her first appointment with her parents. During
the session, Lina was quiet and avoided eye contact, while her mother dominated most of the
conversation. Lina’s mom described her daughter as “difficult and disobedient” at home. She gave
examples of Lina refusing to do her chores and getting into fights with her siblings; her mother also
suspects that Lina is stealing money. Lina is the oldest of her siblings; she has four sisters, and one
brother. Her mother added that Lina should be getting married to one of her father’s friends, and they
are concerned that if she continues with her “bad behavior,” the engagement could be in jeopardy.
The case manager asks to meet with Lina individually for the next session to understand her
perspective, but her parents refuse, saying: “We are her family, we want to know what is wrong so
we can fix her.” The following session, the case manager meets with the family at home and realizes
that they are living in difficult circumstances. There are only two bedrooms, and Lina shares a room
with her 4 sisters. Her parents describe in the meeting that Lina’s father only works sporadically as a
carpenter, and they struggle to pay their bills.
41
 Sometimes they do not buy groceries so that they can make rent and basic bills at the end of
the month. They express that they are growing anxious about Lina’s engagement, and ask you to
“change her bad behaviors soon.”

Case #2
Amer is an 18 year old male who lives with his mother and three brothers. He came to the clinic
because his family members are worried about his “strange behaviors that have been getting worse
and worse.” They described that Amer opens the front door to their apartment several times in a
row (at least 10 times) throughout the day, and that when he is eating he puts his spoon on and
off his plate over and over, without eating anything. Amer explained that he feels “very stressed,
like something is controlling me.” In addition, Amer’s mother stated that he is increasingly irritable
and has started refusing to attend school. Amer said he can’t go to school because he cannot
concentrate, and he feels afraid that the teachers and his peers don’t like him. The psychiatrist at
the clinic has diagnosed Amer with Obsessive Compulsive Disorder with psychotic features, and has
prescribed medication to help. Amer has fervently rejected the medications, and has explained that
if he takes them, “things will get worse, and they will control me.” The psychiatrist has recommended
that Amer’s mother put the medications into his food or drinks to help decrease his symptoms, but
as the case manager you are uncertain if this is the most helpful way to gain his trust and help him
in the long run. You are worried, however, about his school attendance and symptoms, which seem
to be getting worse.

Case #3
Ahmed is 45-year-old male who has been referred to your agency from UNRWA for mental health
treatment. His case manager called about the referral and warned your agency that Ahmed is
“manipulative and will try to take advantage” of services. When you meet him, Ahmed appears
anxious and he fidgets the entire appointment, constantly looking at the door and the window.
His primary complaint in the appointment was sleeplessness and high anxiety. Ahmed stated in
the first appointment, “I always feel afraid that I will be killed, and that someone is out to get me.”
He explained that his life has been very stressful the past five years; his family has received many
threats (bullets left on his doorstep and in the mail) and their neighbors were killed in an attack a
few years ago. Because of his anxiety and desire to protect his family (he has three young children),
Ahmed explained that they have moved many times. He is worried all the time, and his employer has
threatened to fire him because he has missed many days from work and is distracted on the job.
Ahmed requests to see the psychiatrist for some medication that can help him calm down and keep
his job.

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 Case #4
Salma is a 74 year old female. She came in for her initial appointment with her son, Faisal, who is
44 years old. Salma’s primary complaint is her “sadness and hopelessness.” She explained that
her husband died two years ago, and since then she has increasingly become more and more
depressed. Faisal agreed with his mother, saying she used to enjoy socializing with other women
in the neighborhood, preparing meals, and calling her family on the phone (her other children and
grandchildren live abroad ); but now she spends most of her time alone in her room with the lights
off. Salma says that the only thing that helps her feel happy now is hearing her grandchildren on the
phone, but she is afraid they don’t want to talk to her because she is so depressed. Faisal thinks he
hears his mother talking to herself, but he doesn’t know what to do to help her. He said, “She seems
so sad, but I am worried that trying to talk to her about it because it will make her more upset.” In her
initial interview, Salma explained that she is sad because she is thinking about all of the hard times in
her life and wishes that she could just be with her husband in heaven.

For each:
List of Primary Concerns__________
1.
2.
3.
Goal A__________
Objective A1__________
Objectives A2__________
Interventions__________
Goal B__________
Objective B1__________
Objective B2__________
Interventions__________

Care Coordination
Real change for a client comes about through receiving, participating, and benefiting from the interventions
and therapies set out in the care plan. A case manager’s role is to arrange for the client to receives these
interventions and therapies and keep track of the progress and satisfaction of the client when they do,
adjusting and intervening where appropriate to support the client and ensure they receive appropriate and
effective care.
These forms are used by case managers in their role of coordinating care and monitoring progress:

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Form 10 Case Management Follow-Up Notes:
A note should accompany each time the case manager or therapist meets, or speaks with the
client or a family member of the client.

Form 11 Missed Appointment Notification:

Document each time there is a missed appointment. These help support case closure for clients that do
not participate, have moved or we are unable to reach them.

Form 12 Phone:
Document used to keep track of telephone calls to the client, friends and family of the client.

Form 13 PsychoEducation Form:

Helps in documenting what you do with the client and their family.

Form 14 Administrative Update Sheet:

This form helps to track administrative cases. These cases are low level cases and require medication
management or just a follow up.

Form 15 Initial Psychiatric Evaluation:

Psychiatricst first impression of the case, will begin to gain a sense of the case.

Form 16 Psychiatric Update Sheet:

Provides a summary of updates on the client and their situation regarding medication and or suggested
changes to the treatment plan.

Form 17 Psychologist / Counseling Session Notes:

Notes written by a psychologist or counslor on their session with clients.

Form 18 Internal Transfer of Client:

Transfer internally from clinic to clinic, leveling a client down or up, or from mental health to protection/
vice-versa.

Monitoring
After setting the care plan, the case manager will meet with the client periodically to evaluate their progress
toward the goals laid out in the plan. That is, the case manager will “monitor” the client’s progress.
Tools that help the case manager do this are below:
• Client Functioning
• HoNoS

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Protection Assessment, Care Planning, and Monitoring
IMC Child Protection Case Management Documents
 File Cover Sheet
 Client Identification (ID, UNHCR, Passport)
 Consent to Receive Services Protection
 Noncompliant Discharge Protection
 Best Interest Assessment
 Best Interest Assessment UASC
 Home Safety Check
Protection Care Plans
 Form 6 Care Plan Child Protection
 Updated Individual Care Plan(s)
UASC Forms
 Multiple Rapid Registration Form
 Tracing Request
 Child Without Address Form
 Child and Adult Verification Forms
 Reunification Form 2pp
 Alternative Care Placement Form
GBV Forms
 Consent Form (Standard)
 GBVIMS Intake Form (standard)
 Assessment Form
 Referral Form
 Follow up Form
 Protection Safety/Emergency
 Mental Health Emergency Protocol
 Protection Risk Assessment
 Protection Safety Plan
Protection Case Management
 Email / Phone Log
Follow-Up Notes
Interagency Referral Form
 Missed Appointment Protection
 Administrative Update Sheet
 Correspondence
 Psychologist/Counseling
 Psychologist Notes Protection

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 Miscellaneous
 Internal Transfer of Client
Discharge
 Discharge Checklist
 Client Family Discharge Information Protection
 Discharge Care Plan Child Protection
 Discharge Summary Protection

Activity #. Possible Referral Challenges

Group Discussion
10 minutes
What do you think might be challenges in this process?
What could possibly happen at each of the steps?
Answers may include:
Client lacks information on the reasons behind referral
Client is not clear as to what to expect from the other service provider
Case manager is not fully aware of the services offered by the other service provider
Focus on inter-sectoral referral as opposed to cross-sectoral referral
Referral is seen as a way to transfer difficult cases
Agencies competing for clients
Disagreement on follow up and feedback procedures, standards
Lack of personal contact between agencies
Others?

Activity#15 . Creating a Service Map

Group activity
1 hours
Objective:
The purpose of this exercise is to create a resource that you can use in your work, a service map or
directory that identifies all of the agencies, and other community supports which you might need to
contact in your case management work.
Instructions:
Identify as many examples as you can of agencies and other community and support mechanisms
that your clients might want to utilize which you might need to connect with / refer to / link with in
your case management work.

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 Instructions:
Identify as many examples as you can of agencies and other community and support mechanisms
that your clients might want to utilize which you might need to connect with / refer to / link with in
your case management work.
Try to include both service providers and activities and natural support mechanisms.
Identify as many examples as you can of supports that your clients might want to utilize.
Think about service providers and their activities (direct services) as well as community or natural
support mechanisms (indirect services).
Make “service map” here or in a separate document, relevant to your area.
Notes:
1. Suitable as homework exercise between sessions
2. Some case managers may already have this resource, or they may have shared ones in their
agency. Options for these people include: spend time updating existing resource, or working with
someone who is starting out, sharing knowledge of networks with staff who are new to the area.

Case managers are encouraged to create and update these resources amongst their team. This includes
the 4Ws service mapping you have completed. You should ensure to keep your 4W mapping up to date
and also consider informal services and supports.
Under “notes” make sure to include and update additional information such as: Need to bring caretaker
with you when you visit, rules about length of stay, feedback about attitude to clients, reputation of service,
whether is staff friendly and helpful, etc

Practice
WHO (agency Where (Location) What When Notes
and main
c o n t a c t
p e r s o n ,
address)

Bokolemayo Melkadida Kobe Activities and Av a i l a b i l i t y T a r g e t M H P S S Tr a i n i n g

!
Services of the beneficiaries R e l a t e d activities
activity and eligibility Staffing or ( t a r g e t
criteria (if any) Protection trainees,
Staffing topics and
length of
training)

Identify as many examples as you can of supports that your clients might want to utilize. Think about
service providers and their activities (direct services) as well as community or natural support mechanisms
(indirect services). Make “service map” here or on a separate piece of paper that is relevant to your area.
(Note: You can start with existing service guides and build onto them.)

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 Direct or Contact Telephone
Service name Location Services provided
Indirect? information number

!
!
! !
!
!
!
!

References and Resources

Agency for Health Care Policy and Research. Smoking Cessation: Clinical Practice Guideline, Number 18.
Washington, DC: U.S. Government Printing Office, 1996.

Bandura, A. Human agency in social cognitive theory. American Psychologist. 1989;44:1175-1184

[PubMed]

Bandura, A. Self-Efficacy: The Exercise of Control. New York: W.H. Freeman, 1997. Bandura, A. Self-
Efficacy: The Exercise of Control

Bien, T.H. "Motivational intervention with alcohol outpatients." Ph.D. diss., University of New Mexico, 1992.

Chamberlain, P.; Patterson, G.; Reid, J.; Kavanaugh, K.; and Forgatch, M. Observation of client resistance.
Behavior Therapy. 1984; 15:144-155

Friedman,M.J. 2000 Post-Traumatic Stress Disorder: The Latest Assessment and Treatment Strategies.
Kansas City, Mo.: Compact Clinicals.

Hepworth, Rooney, Rooney & Strom-Gottfried. Direct Social Work Practice: Theory and Skills 9th Edition.
{2010} p. 48-49.

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