Friday, March 12, 2010

The Informed Consent Process

Is evidence of informed consent more than just a signature on a page?

I contend that informed consent is a complex process beginning at engagement and important at every step of the social work process - assessment, diagnosis, treatment planning, intervention, evaluation and termination.

When I work with a student of any age, I make it a point to engage the parent/guardian early on. Otherwise, I feel that I am treating a disembodied student. Does a student exist or survive outside of the family system, no matter what the age? Unless they are orphans living in an institution or emancipated and living on the streets, they have a "family" with all the corresponding responsibility, relationship capacity and love that makes healing, transformation and growth possible - even if it is not obvious at first glance.

Sometimes when we go to the supermarket, my daughter runs into the parent of a classmate who says to her, "Hi, Paolina!" - while completely ignoring me! At this point, rather than feel like an invisible victim, I might be empowered to introduce myself, "Hi, I'm Paolina's mom, Alejandra."

Not engaging parents/guardians in child treatment feels disrespectful and shortsighted to me. Disrespectful because it is acting like parents/guardians are wallflowers (o pintados en la pared), invisible, not taken into account (no tomados en cuenta), irrelevent, unimportant. Shortsighted because parents/guardians and family members generally love and care about their kids more than anyone else on the planet, including dedicated social workers. It's like saying: I will direct my conversation and intervention to the child, the person with the least amount of power in the family system. I will ignore the parents and their love, commitment, responsibility and role in their child's life.

Now I realize that working with parents is not easy and generally speaking, does not come naturally to most of us. While all the literature explicitly points to parent and family involvement as one of the most powerful factors for academic achievement and social-emotional-behavioral health and resiliency, not all school personnel feel adequately trained, confident or competent to reach out.

I was thinking about all the things that fell into place for me to be able to confidently and skillfully reach out to parents.

Unless an administrator, school counselor, teacher or dean walks the parent over to my office for our first introduction or meeting (which I encourage), I am usually calling the parent on the phone soon after receiving the written or verbal referral. Doing cold-call telemarketing to earn money while I was in college really helped me to overcome the fear of meeting someone on the phone and communicating persuasively. In order to remove the "cold-call" barrier, I try get someone that the parent trusts to broker the introduction. Also, I ask the teacher or administrator to share their concerns for referral with the parent before I contact them.

Second, it helps to have a script. My "script" has evolved over time. In my second year MSW field placement at an elementary school, my field instructor had us role play how to talk to parents on the first day. In my first professional school-based assignment, I regularly called parents because this was part of my graduate school training and because my clinical supervisor for licensure hours was very family therapy-focused, also. Back then, I only got about a 50% parent/guardian engagement rate. I thought this was very bad and complained to my mentor, Reevah, about this. She taught me that parents get very easily put on the defensive when they get a call from school (sadly, it is rarely good news). They either feel that they are in trouble with the Principal (flashbacks) and come out fighting or are overwhelmed by the child's behavior too and don't know what else to do. In the latter scenario, parents will either ask for help or "fight back" as a defense against feeling incompetent or blamed as parents. It is sometimes easier to blame others first and slip into denial than to take responsibility and ask for help. This is true for all of us, let's not kid ourselves.

So my rap to parents evolved. Now it goes something like this:
"Hi, my name is...I am a school social worker and my role at the school is to make sure that every student is successful. I understand your son/daughter has had some challenges at school...I would like to meet with you to talk about how we can work together as a team to make sure that your son/daughter is doing well at school. You are the most important person in your child's life and I can't imagine being able to do this without you. I noticed that your child is really good at..."

I try to talk to the teacher and other school staff, review the cum, etc. to identify the child's strengths before I make the call. Every kid has got them and highlighting these strengths in my conversation with the parent let's them know - I get your child - I know how wonderful and important they are to you - I don't see your child as solely a checklist of risk factors or a problem student - you've done a lot of good things as a parent before I ever picked up the phone to call you.

My parent/guardian engagment rate went from 50% in a South LA elementary school to 90% at two different high schools (East LA and the Valley) and finally, nearly 99% at another South LA elementary school. I became skillful which increased my confidence, expectation and hope, which in turn gave me the encouragement I needed to continue practicing which made me more skillful, etc.

My first meeting with parents is usually at the school (most prefer this to a home visit, although I've done those too). This is when I begin conducting the biopsychosocial (BPS) assessment. Ironically, I did not learn how to do this until August, 1998 - two years post-Masters! I didn't know that I didn't know until I participated in a back-to-work training about time-limited assessments. The social worker sitting next to me in the training complained that it was so basic but I vigorously took notes because it was literally the first time that I was exposed to this type of training. No wonder my field instructor wondered why I didn't conduct developmental assessments! Suddenly I was embarrassed by a write-up I had done for a fellow CPS (child protective services) worker who requested that I interview his client. She would only speak to a female spanish-speaking social worker and I fit the bill. It was a lovely home visit and she really opened up. But after this BPS assessment training, I realized that for all my prose and inquiry - I had not delivered an assessment report! Oh well, you live and learn.

I remember the BPS trainer saying how after the longest part of the interview (presenting problem), you should be able to develop a "short list" of potential diagnoses. Subsequent interview questions help to rule things out. With a clear, objective, behavioral list of problems, it is easier to determine priorities - what to work on first. This leads into treatment planning rather smoothly. That is, taking prioritized presenting problems and developing goals - what do you want your child to be doing instead? Finally, how will we get there? What works to accomplish these goals? What's it going to take? Who will do what? Planful, thoughtful and clear - a road map making it more likely to get there sooner and less likely to get lost and confused along the way.

At this stage, parents are truly informed to consent to treatment. You can confidently say - this is what we will work on and why. This is how we will work on it and why. Now parents enter this agreement with their eyes open and with a fuller understanding - informed. They were part of the process and the conversation every step of the way. They know what, when, where, why and how and the risks and benefits - full disclosure. Would you, as a parent, want or expect any less?

I also realize that my training as an HIV Pre/Post Test Counselor and then as a Trainer of HIV Test Counselors emphasized the concept and process of informed consent. Clients did not sign the informed consent form to take the HIV test until we had discussed: What is HIV? What does the HIV antibody test look for? What do the results mean? What are the risks and benefits of taking the test? and more. If a client doesn't get his blood drawn for the test until both counselor and client are confidently clear about what the client is about to do, then how do we reach the same level of clarity when working with parents and their children as they consent for mental health treatment?

Sometimes we don't have a plan. We don't know where we are going and we hope they don't ask. Even if they don't ask, we ought to know and we ought to tell them. Don't you think? I didn't always know how to plan. I have learned everything along the way - reading, training, practice. When I worked for Sonoma County, doing child protective services work, I attended a training about child welfare risk assessment and case planning. I loved how the professor encouraged us to write individualized case plans. That is, rather than recycle boilerplate language so that every client has the exact same case plan, he taught us to think about - what puts a singular child at risk exactly? and what do parents need to do differently so the child is no longer at risk? He talked about writing goals in positive terms - what to do instead of what not to do. For instance, when climbing, is it a better idea to say "look up" or "don't look down" - which is more likely to get the desired response?

When training social work interns, I was committed to making sure that they did not graduate with the gaps in practice knowledge that I experienced in mine. To that end, I sought out information, books, training, consultation and practice in BPS assessment, diagnosis and treatment planning. In the process of teaching them, I learned a lot myself. I am so grateful for that process now.

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