Intro to Social Work

SW124
Chapter Five
Emotional/Behavioral Problems and Counseling
What is Mental Illness? Medical Model and Interactional Model
Medical Model views emotional and behavioral problems as mental illness, comparable to physical
illness
A belief that the disturbed person’s mind is affected by some generally unknown internal condition
which can be due to genetics, metabolic disorders, infectious diseases, internal conflicts, unconscious
use of defense mechanism, or traumatic early experiences that cause emotional fixations and prevent
future psychological growth
Major evidence – medical-model comes from studies that some mental disorders, such as
schizophrenia, influenced by genetics – ex. twins
DSM-IV Diagnosis Categories
Disorders usually diagnosed in infancy, childhood, or adolescence – mental retardation, etc.
Delirium, Dementia, and Amnesic and Other Cognitive Disorders - Delirium due to alcohol/drugs,
Alzheimer’s, Parkinson’s, head trauma.
Substance -Related Disorders – mental disorders related to abuse of alcohol, caffeine, amphetamines,
cocaine, etc.
Schizophrenia and Other-Psychotic Disorders – delusional disorders and all forms of schizophrenia –
effect and behavior that last longer than 6 months
Mood Disorders – emotional disorders such as depression and bipolar disorders
Somatoform Disorders – manifest as a physical disease – hypochondria
Anxiety Disorders – phobias, posttraumatic stress disorder, etc.
Dissociative Disorders – part of the personality is dissociated from the rest such as dissociative identity
disorder (formerly called multiple personality disorder)
Sexual and Gender Identity Disorders – sexual dysfunctions, exhibitionism, fetishism, pedophilia, etc.
(cross-gender identification is included only to the extent that extensive counseling is needed to
determine the basis (included only to the extent that extensive counseling is needed to determine the
basis if new assignment is sought)
Eating Disorders – anorexia nervosa, bulimia nervosa, & compulsive overeating
Sleep Disorders – insomnia, nightmares, sleepwalking, etc.
Impulse-Control Disorders – inability to control certain undesirable impulses ex. Kleptomania,
pyromania, pathological gambling
Adjustment Disorders – adjusting to stress created by common events as unemployment or divorce

Personality Disorders – enduring pattern of inner experience and behavior that deviates markedly from
the expectation of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or
early adulthood, is stable over time and leads to distress or impairment

Paranoid – pattern of distrust and suspiciousness, such that others’ motives are interpreted as
malevolent
Schizoid – pattern of detachment from social relationships and a restricted range of emotional
expression
Schizotypal – pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and
eccentricities of behavior
Antisocial – pattern of disregard for and violation of, the rights of others
Borderline – pattern of instability in interpersonal relationships, self-image, and affects and impulsivity
Histrionic – pattern of excessive emotionality and attention seeking
Narcissistic – pattern of grandiosity, need for admiration, lack of empathy
Avoidant – pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative
evaluation
Dependent – pattern of submissive and clinging behavior related to an excessive need to be taken care
of
Obsessive-Compulsive – pattern of preoccupation with orderliness, perfectionism and control
Interactional Model
The idea that mental illness is a myth-that it does not exist
3 types of emotional/behavioral disorders
Personal disabilities – excessive anxiety, depression, fears, feelings of inadequacy – (unwanted
emotions) (not disease)
Antisocial acts- bizarre homicides and other social deviations
Deterioration of the brain with associated personality changes – Alzheimer’s disease, arteriosclerosis,
chronic alcoholism, AIDS, or serious brain damage caused by an accident
Medical labels have adverse effects – people believe that have a disease for which there may be no
known cure - give people an excuse to not take responsibility for their behaviors
Labeling as the Cause of Chronic “Mental Illness”
Despite extensive research the determinants of chronic mental disorders are largely unknown
Everyone at some time or another violates what are considered social “norms” – usually this is not
considered mental illness
When that violation is perceived by others as “abnormal” the offenders are labeled “mentally ill” and
the person also begins to define themselves as mentally ill
If they try to return to their previous behaviors they are viewed with suspicion
The more they are related to as mentally ill the more they begin to accept the diagnosis

The Homeless
25% to 50% of the homeless are thought to suffer from serious and chronic form of mental illness
I. Discharged from institutions without the support they need
Many states have a deinstitutionalization program of simply drugging people and dumping them into
the street
This was not the original intent of the mental health act
Cutbacks in social services by the federal government prevents communities from providing for this
population
Solutions including – low-cost housing, job services for those with emotional problems, job placement
and training
As a society presently we prefer to pretend they do not exist
Civil Rights
Striking an acceptable balance between the disturbed person’s right to liberty and society’s right to
safety and protection is complex
In some mental hospitals patients do not receive adequate treatment – this is a violation of the Mental
health act of 1964
Decisions about providing treatments such as electroconvulsive therapy raise civil rights questions and
severely disturbed are often unable to make rational choices about their own welfare
Federal court decisions have held that mental illness is not a sufficient basis for denying liberty and that
hospitalized mental patients have a right to either adequate treatment or release
Plea of Innocent by Reason of Insanity
Dan White – found innocent by reason of insanity – even though testimony clearly showed murders
had been carefully planned – Twinkie Defense
Among psychiatrists there is nothing approaching a consensus on what constitutes insanity
Criminals are able to manipulate the system
Some states are revising laws – some to eliminate the insanity plea – others have a two-step process
Use of Psychotropic Drug
Psychotropic drugs include tranquilizers, antipsychotic drugs (such as Thorazine), and antidepressants
Psychotropic drugs do not “cure” emotional problems, but are useful in reducing high levels of anxiety,
depression, and tension. They also reduce some symptoms such as the hearing of voices and
hallucinations
Because they only provide temporary relief many authorities urge that patients also receiving
counseling or psychotherapy to help resolve the underlying emotional difficulties

Managed Health Care

Managed Health care is a generic term used to describe a variety of methods of and financing health-
care services designed to contain the costs of service delivery while maintaining a defined level of
quality of care (HMO)
There has been severe reductions in the number of days that managed health care will reimburse
impatient treatment centers
More and more people with emotional and behavioral problems are increasingly only receiving drug
therapy than “talk” therapy
Social Structure and Mental Illness
Social Class – the poor are more likely to be labeled mentally ill – they are less likely to seek treatment
early
Urbanization – inner-city area may have a higher rate of mental illness – overcrowding – quality of life
Age – elderly are more likely to have emotional problems, particularly depression – low status – brain
degeneration – grief
Marital Status – single, divorced, or widowed have higher rates – unmarried men have a higher rate
than unmarried women
Sex – equal but nature of diagnosis varies – women, anxiety, depression, phobias and to be
hospitalized; men, personality disorder – most psychiatrists are men and are more apt to consider
sexual promiscuity or aggressive behavior in women a mental order as compared to men
Race – compared to Whites, African Americans are more like to be diagnoses as mentally ill and there’s
a higher rate of hospitalization – AA under greater psychological pressure, many in lower socio-
economic status, psychiatrist are White
Social Work and Mental Health
Many social agencies in addition to the community mental health centers provide psychotherapy to
people, schools, family counseling agencies, social service departments, hospitals, adoption agencies,
probation and parole depts.
SWs who want to be involved in private practice must have a master’s or doctoral degree in social
work from an accredited graduate school, two years or 3,000 hours of postgraduate clinical social work
experience, supervised by a clinical social worker, active membership in the Academy of Certified
Social Workers or a state license that requires an examination
A skilled counselor has knowledge of (a) interviewing principles and (b) comprehensive and specific
treatment approaches
Phases of Counseling
(1) Building a Relationship

(2) exploring problems in depth

(3) exploring alternative solutions

Building a Relationship
Seek to establish a nonthreatening atmosphere
You need to present yourself as a knowledgeable, understanding person
Be calm – do not laugh or express shock when the counselee begins to open up about problems
Generally be nonjudgmental and nonmoralistic – show respect for the counselee’s values and do not try
to sell your own values
View the counselee as an equal, (many rookies make mistake of being superior and creating a
superior/inferior relationship)
Use “shared vocabulary” – not slang or coping – but use words that the counselee understands and that
are not offensive
Tone of voice should convey the message that you empathetically understand and care about the
counselee’s feelings
Keep confidential what the counselee has said
If possible refrain from counseling friends or relatives because emotional involvement interferes with
the calm, detached perspective that is needed to help clients explore problems and alternative solution
Exploring Problems in Depth
A counselor should take the time to discover the client’s in depth opinions and feelings on a course of
action before suggesting solutions
The Counselor and the clients need to examine such areas as the extent of the problem, its duration, its
causes, the counselee’s feelings about the problem, and the physical and mental capacities and
strengths the counselee has to cope with the problem
When a problem area is identified, a number of smaller problems may occur, explore all these sub-
problems – usually it helps to solve a subset problem first. Ask the client which of those subset
problems does he/she find the most pressing
Convey empathy not Sympathy
Trust your instincts. The most important tool you have as a counselor is yourself – rely on your
feelings, perceptions and training
When you believe a client has touched on an important area of concern, you can encourage further
communication by nonverbally showing interest or pausing (don’t be afraid to pause), using neutral
probes, summarizing what the client is saying, reflecting feelings.
When pointing out a limitation that a client has, also mention and compliment him or her on any assets.
Watch for nonverbal cues
Be honest
Listen attentively to what the client is saying – try to hear the words not from your perspective but from
the client’s.
Exploring Alternative Solutions
It is almost always best for the counselor to begin by asking something like “Have you thought about
way to resolve this?” If the client not thought of certain viable alternatives, the counselor should
mention these, and the merits and shortcomings to these alternatives
The client usually has the right to self-determination – counselor’s role is to help the client clarify and
understand the likely consequences of each alternative – at the same not to give advice or choose the
alternative “Have you thought about as opposed to I think you should”
Counseling is done with the client, not to or for the client – client should take responsibility for those
task that they have the capacity to accomplish
Form explicit, realistic “contracts” with counselees – when the counselee selects and alternative, they
should clearly understand the goals, tasks and who will do what
If the counselee fails to meet the terms of the “contact” do not punish, but do not accept excuses. Ask
the clients if they wish to continue to try and meet their commitment
If the counselee fails to meet the terms of the “contact” do not punish, but do not accept excuses. Ask
the clients if they wish to continue to try and meet their commitment
A counselor should seek to motive apathetic clients – sometimes clients do not have the motivation to
fulfill contracts
One way to increase motivation is to clarify what will be gained by meeting the commitment when a
commitment is met reward the clients with an affirmation
If necessary help the client to “role-play” the tasks – this can be done by having the counselor at first
role play the client’s role and then the client plays herself
When to Refer to Another Counselor
If the counselor feels that she or he is unable to empathize with the client
If the counselor feels that the counselee is choosing alternatives that conflict with the counselor’s basic
value system
If the counselor feels that the problem is of such a nature that she or he will not be able to help
If a working relationship is not established
A competent counselor knows that she or he can work with and help some people but not all.