Social History (Assessment Part 2)

An important element to completing the comprehensive assessment is conducting a social history of the client. This can be quite valuable in that it helps the clinician understand the client’s violence in a larger life context. It also helps the client to appreciate their psychological complexity and even possibly develop insights into the etiology of their violent behaviors. The social history also helps he client become more comfortable with the process of self-disclosure that will be an integral element of the group therapy experience.

The social history should consist of data in the following domains.

Educational history
Employment/financial history
Family history
Learning disability history
Marital/relationship history
Medical history
Mental health history
Physical disability history
Psychoactive substance history (alcohol and drug screen)
Psychoactive substance history in family of origin
Support systems
Trauma history (physical and psychological)

An example of a brief Social History Protocol is included in the Forms of this workshop.

Who Conducts the Assessment and for How Long?

Ideally, clinicians running the treatment groups should conduct all initial assessment interviews because they are intimately familiar with the group’s unique composition and dynamics. The purpose of this is so that clients can be best matched to the most appropriate groups. The idea of what constitutes a good match will be discussed later. The initial interview is approximately ninety minutes. This give the therapist and the client sufficient time to discuss the acts of violence that triggered the referral, procure some initial psychosocial history and provide some initial interventions to prevent further violence. The initial interview is typically followed by three to five fifty-minute sessions. During this time the clinician procuring additional psychosocial history, assessing motivation and suitability and developing rapport. Some assessments may be extended whereas others may be shorter in duration. The purpose of the interviews is to determine the most appropriate treatment plan, therefore however long that takes will ultimately be determined by the client and his or her circumstances and the style of the therapist.

Procuring a Signed Authorization to Release Information

Clinicians should be aware that working with perpetrators of domestic violence poses a number of important legal and ethical concerns. Before conducting the first interview, clients must sign an Authorization to Release Information - Probation (see Forms), so that the clinician may contact the probation officer of the appointment. Some clients may be reluctant to sign this form prior to meeting with the therapist. This presents an interesting dilemma. On one hand, the client is mandated to a specific program by the court or probation and therefore really doesn’t have any choice in the matter, other than to have his or her attorney object to the court. On the other hand, some probation departments give the client the names of multiple programs and allow the client to choose which program he or she would like to participate in. In the later case, it may make sense for the client to meet with the therapist or program coordinator, prior to starting the formal evaluation process to determine if the program philosophy and approach is congruent with his or her needs and values. However, in both cases, the question remains, does the client have a right to check out the program before agreeing to sign an authorization to release information? Most importantly, it may be difficulty for a client to speak candidly if he or she believes that the therapist will report information to the probation officer or the court. Here lies one of the conflicts that plagues many court mandated mental health treatment programs across the country. Is the mental health provider’s first duty to creating a safe and therapeutic environment for the prospective patient or to helping the system, that is making the referral in the first place, to enforce the law? Legal and mental health scholars have pondered these conflicts for many years and a simple and clearly defined solution does not seem to exist.

Needs of mental health providers and the needs of criminal justice personnel working with domestic violence perpetrators may at times be in conflict but they may not be altogether irreconcilable. The most important process is that services providers meet with criminal justice personnel and find creative solutions to these and other conflicts. If the professionals can’t work out their conflicts, how can we expect our clients to work out theirs?

Generally, it’s a good idea to procure, at the minimum, a modified authorization to release information (see handout) prior to starting the assessment process. This allows the therapist to at the least acknowledge the client’s presence so that the client has spent some time with the therapist before signing a more comprehensive release.

The problem of privacy is further complicated by many domestic violence clients’ tendency to manipulate the system to avoid responsibility and to defend against feelings of defectiveness, insecurity, etc. Some clients may use the issue of the release to avoid dealing with their issues that brought about the referral in the first place. Therefore, therapist’s need to be careful to not let themselves get seduced into the client’s acting-out or testing of the clinician.

Back to the logistical issue of releases, similar to the above criminal justice contacts, clients are required to sign an Authorization to Release Information - Partner (see Forms) so that the clinician may have contact with his/her partner during the assessment process as well as during treatment. The purpose of this contact is to assess progress in treatment, as well as determine the needs for other mental health interventions (e.g., couples, family, individual).

Additionally, the client must sign the Authorizations to Release Information - Other (see handout) so that other professionals may be contacted (other mental health professionals, medical personal, social worker, religious or spiritual, etc.) in order to complete the assessment process.

The client should be informed of the specific purposes of these contacts in writing, but it is good practice to tell the client verbally as well. Most clients cooperate with the completion of these releases, but don’t always assume that failure to immediately cooperate is a sign of resistance. Generally, exploring their fears of the disclosure, and what exactly you will be revealing to the other party may allay concerns or vulnerabilities. Although a client does ultimately sign an authorization to release information, the therapist can reassure the client that the therapist will use discretion in their conversations with the outside parties. Lastly, one can argue, that the client lost their right to confidential treatment, when their personal problems were brought to the attention of the criminal justice system. However, regardless of this limitation, the client will retain some considerable element of privacy. Lastly, the client should also be reminded that even though he or she may not have complete confidentiality (no client can be guaranteed of this), nevertheless much could be gained from the therapeutic process.

The Assessment Process: Review

The assessment interview is to cover the following topics:

1. Completion of The Client Social History Form (see handout)

2. Narrative report of violence.

3. Completion of Spouse Abuse History Form (see handout).

4. Completion of Risk Assessment (see handout).

5. Completion of Child Abuse History Form (extended interviews) (see handout).

6. Completion of Child Abuse Injury Form (extended interviews) (see handout).

7. Each client must be assessed for current child maltreatment, suicidality and dangerousness towards others.

8. Completion of an alcohol and drug screen

9. Each client must be assessed for motivation for treatment.

10. Each client must be given a provisional psychiatric diagnosis per DSM-IV.

11. Clients may be given a psychological test(s) (extended interviews).

12. Procure all the necessary release of information forms.

Clients must be given a verbal and written description of the program. In particular, the clinician should go over number-by-number the program rules to make sure the client is in full agreement prior to commencing treatment. Subsequent to the assessment interviews with the perpetrator, the intake interviewer is to make the following collateral contacts prior to admitting the client to the program:

Telephone call/interview with partner: The purpose of this interview is to a) obtain a violence history; b) assess the current offense; and c) explain the rules and expectations of the program. The partner is told that he/she should call the police and/or probation department as well as the domestic violence program to report additional acts of physical, sexual or psychological violence. The partner is also informed that if the client is accepted into the program, he/she will be contacted at least once a month to help or assist in assessing client progress.
Contact with the probation officer: Prior to client being accepted into the program, the clinician should contact the referring probation officer to determine if there is any issues relating to the offense or victim that would be useful prior to completing the assessment process. Often times, probation officers have had contact with the victim or other family members. Additionally, probation officers will have criminal history information, which can be valuable to the risk assessment process.
Other necessary collateral contacts (e.g. therapist, substance abuse evaluators, psychiatrist, etc.): The intake interviewer is to contact other mental health professionals currently treating the client before admitting the him//her into the program. These contacts could yield valuable information regarding diagnosis, treatment compliance, coordination of provider interventions, etc.

In determining the client’s suitability for the group treatment program, the intake interviewer may take into consideration, but is not limited to, the following issues:

Work schedule: Is client is able to consistently attend weekly sessions?
Is this person able to control his or her behavior with once a week counseling?
Does this person have a serious substance abuse problem and is he/she therefore in need of prior or concurrent substance abuse treatment?
Does this person have any other serious psychiatric problem that will interfere with treatment, and can he or she emotionally manage the treatment process (confrontation, peer interactions, etc.)?
Does this client have any learning disabilities that may interfere with the educational component of the program?
Does the client state that he/she is willing to comply with all program rules?
Is this client in crisis and needing individualized attention?
Does this client have a history of psychological treatment failures?
Client has at least average intelligence and is literate in the language that is utilized by the program.
Cultural issues that may contraindicate this treatment modality.

In determining the client’s motivation for the program, the intake interviewer may take into consideration, but is not limited to, the following issues:

Client acknowledges that he/she can benefit from program.
Client appeared at intake appointment on time.
Client states he/she is willing to complete program.
Client states he/she is willing to pay for treatment program.
Client completes all paper work.
Client expresses remorse and a willingness to change his/her violent behavior patterns.

During the initial interview the client is explained the Program Rules (see handout) and Client Evaluation Guidelines (see handout). There is a clear understanding that the program will periodically contact the person who was injured to assess safety, provide information about services available (legal aid, counseling shelters, Victim/Witness programs, etc.) and assess program effectiveness. Additionally, because many clients have permanently separated from the person whom they assaulted or are in multiple relationships, the program will have contact with any new intimate partner the client may be with while in treatment as well as any other person whom the clinical staff deems necessary to assess safety and progress in treatment.

Matching the Client to the Right Group

The purpose of this is so that clients can be best matched to the most appropriate groups. For example, a group with a critical mass of poorly motivated clients may need a few clients who are more willing to look at their problems. Likewise, a client who is poorly motivated may work better in a group with more advanced clients who are already addressing psychological issues associated with their violence. Other issues to consider may include: alcohol and drug history, educational or literacy issues, severity of prior history of violence or involvement with criminal justice system, language, ethnicity, social class, sexual orientation, gender, marital or relationship status to name a few. What is most important is that take into consideration multiple factors when matching a client to a particular group.

Some therapists have expressed concern about mixing court mandated with self-referred clients. I see no particular problem with this combination as long as all clients, both court mandated and self-referred, are held to the same standards regarding the program rules and expectations.

Clients who are not accepted into the Program

If a court-mandated client is not accepted into the program due either to lack of motivation or suitability, or the client refuses to comply with program rules and procedures, that person should be referred back to the Probation Department. Generally, it is not a good idea to refer that client to another program. You may make a recommendation to the probation officer in the Progress/Enrollment/Termination Report (see Forms), but it is best that the probation officer make that referral to the client. A Progress/Enrollment/ Termination Report (see Forms) should be completed and immediately mailed or faxed to the probation department. If the client needs to reappear in court in the next few days, the client may be given a copy of the Progress/Enrollment/Termination Report (see Forms) to take with him/her.

Clients who are accepted into the Program

When the client has been accepted into the program, the client should meet with the group leader to schedule a final pre-group screening interview, if the clinician conducting the assessment does not lead that particular group. The purpose of the interview is so the client can meet his/her therapist in order to make the transition from assessment to treatment more smoothly. The group leader should examine the completed chart (with the appropriate forms) prior to this pre-screening interview. The designated group leader should contact the client within 48 hours to set up a final screening appointment. The group leader should meet with the client for approximately 30 minutes to orient him/her to the group experience, including: how the group check-in is conducted, homework assignments, the use of the anger journal, time outs and a confirmation of time, place and fee. The group leader should go over the payment policies and make sure that the client has copies of the Group Rules, Evaluation Guidelines and Fee and Payment Policies (see Forms).

All clients accepted into the program must understand that their status is provisional - in that they must demonstrate during the first twelve weeks a commitment to working on the issues that lead to their violent behaviors. Motivation and suitability will be reassessed at that time and that continued participation in the program will depend on their participation in the group. Clients also need to be reminded that therapy is a process of continuing evaluation and that clients will received regular feedback from their therapist(s) regarding their progress in treatment.

Progress/Enrollment/Termination Reports should be sent to the supervising probation officer every four weeks during the early stages in treatment and every 8-12 weeks in the later stages of treatment. These reports may include attendance, punctuality, additional acts of violence, compliance with homework and a brief summary of the client’s progress. It is the client’s responsibility to request any other necessary reports at least two weeks in advance of its due date.

If the clinician determines that the client needs additional treatment or other interventions, he/she must create a behaviorally based treatment plan in collaboration with the client and send that plan to probation with a Progress/Enrollment/Termination Report (see Forms). In some cases, the clinician will recommend continued treatment in a modality other than the group. In this case, the treatment plan should include the rationale for the change in modality and, if the client is being given an “outside” referral, three names of potential providers.

Victim/Partner Contact

Because many clients tend to minimize and deny their violence and the probability that some participants are likely to continue their violent behaviors, clinicians should contact the partner and obtain a violence history from her/him and inform that person of the inherent limitations of treatment. This initial contact is made during the assessment process. Additionally, partners are encouraged to utilize the criminal (call police and/or probation if another incident of violence occurs) and civil (temporary restraining orders, separation/divorce) justice systems for relief from victimization. Partners are also provided with information regarding services (such as shelters, battered women's groups, legal aid, etc.). Partners are encouraged to develop a safety plan in the event that violence becomes imminent. Of course, the clinician will notify a partner in the event it is assessed that that person is in immediate danger.

Group leaders should contact the partner at a minimum of once a month. For some high-risk cases, this contact may be more frequent. The purpose of the this contact is as follows:

To determine if the client has perpetrated any acts of physical, sexual or psychological violence since the most recent arrest.
To determine if the client is taking Time-Outs.
To determine if the client is utilizing other anger management and social problem solving techniques.
To determine if any crisis or volatile situations are occurring.
Refer partner for counseling, shelter, etc. if necessary.

The group leader is to complete the Victim Contact Forms (see Forms) which is to be included in the client chart. Clients need to be continually reminded that the program is contacting the partner and that any threats or intimidation of the partner regarding this contact will result in their immediate termination from the program. In some juristidictions, probation officers will contact the partners of your clients to assess how things are going at home. It doesn't really matter who does that piece, it just needs to be done and communicated to the treating therapists.

Legal Issues: Collateral Contacts

Clinicians should be aware that collateral contacts with other persons (such as a partner) and professionals (such as a probation officer) are not agency clients, and therefore there does not exist a psychotherapist-client relationship. However, contact with victims pose a number of important legal and ethical concerns.

Informed consent: From the onset of treatment, clients must be required to sign an authorization to release information so that the clinician may have contact with his/her partner. The client must be told that the purpose of these contacts are to determine if he/she has continued to perpetrate additional acts of physical, sexual or psychological violence and if he/she is utilizing the program interventions at home. Clients must be told that information provided by the partner will be shared with the client and probation, as the clinician deems appropriate.

The partner should be informed at the initial contact that she/he is not your patient and therefore information that is shared with you may be disclosed to the client (perpetrator) and/or probation, as you deem appropriate. This statement should also be given in writing to the partner.

Danger to others: When the partner discloses either additional acts of violence or other program noncompliance by the client that increases the risk of additional acts of violence, the clinician should encourage the partner to report this information directly to the probation officer. If the clinician determines that confronting the client with this information places the partner in danger, the clinician must work with the partner and the probation officer to minimize this risk through coordinated intervention. Clinical staff should collaborate whenever dangerous situations arise where confidentiality or other legal issues need to be considered.

Reporting Acts of Violence: All acts of physical and sexual violence, and some forms of psychological violence (e.g., threats to kill, threats of violence, attempts at violence (assaults, stalking) must be reported to probation within twenty-four hours. Psychological violence consisting of illegal acts (threats and stalking), as well as acts resulting in serious psychological harm are required to be reported to probation.

For all acts of violence (reportable and non-reportable) a Critical Incident Report(see Forms) must be completed and placed in the client’s chart. Additionally, all reported incidents of violence must be included in the client chart, including a description of the violence, treatment plan changes, all collateral contacts (victim, probation, supervision/consultation, collaboration with mental health providers, etc.).

Client Fees

The client’s fee is determined based upon income and the number of dependents as determined by a standardized Co-payment Fee Schedule (see handout). An assessment fee should be determined and client must be informed of this at the time he/she makes the initial appointment. The Fee and Payment Policies (see Forms) must be clearly outlined at the initial interview. The intake interviewer will assess the client’s fees. Generally it is a good idea to expect clients to pay for services at the time they are rendered. Clients should not be allowed to become more than two weeks behind in payment.

Money is almost always an issue in treating the court-mandated client. Monetary issues are rarely straightforward and therefore are likely arise for multiple reasons. First, court mandated clients are generally less motivated than self-referred clients who usually seek services as a result of their own realization of their need for treatment or the value of such services. The court mandated client is usually not recognizing that he/she is having a problem at all. These clients typically view their partner or the system as the problem rather than themselves. Although some of these clients may be have been shocked into recognizing their need for treatment as a result of their arrest and conviction, however these more-motivated individuals are far and few between.

Another reason clients may bring up financial issues is because many clients who enter into treatment through the criminal justice system are poor, unemployed or underemployed. Many of these clients have multiple psychosocial stressors violence only being one of them. Those clients who are a part of the working-poor in this country may not have qualified for public legal assistance and therefore may have paid exorbitant legal fees as a result of their defending themselves in court. Additionally, many “male” clients who are referred by the criminal justice system do not see the value of psychotherapy and therefore this attitude is likely to get played out in the financial arena.

For many clients, their culture may include prohibitions of talking to non-family members about personal problems, let alone paying for their services. For many people, paying a therapist for their services creates tremendous feelings for clients in that it is a symbolic acknowledgement of the client’s need. These feelings may also include fears of dependency on the therapist. Many clients do not understand why one must pay for caring, or paying to have a friend to talk to. In therapy, what one is paying for is not material and therefore is not always immediately apparent to the client. For these and other reasons, money represents a multitude of issues for the court mandated client and therefore must be addressed both pragmatically as well as clinically.