Therapeutic Relationship

The therapeutic relationship is a working relationship in order to best meet the needs of the client. There are several facets of the relationships that will be explored here.

First and foremost, the differences between the social worker and client can be a source of hesitancy in working together but if the two can still create a safe and inviting working relationship, this can help the client progress in even more ways.
Clients who are older working with a younger social worker may feel as though the social worker does not understand his/her plight. Furthermore, a younger social worker may look at all older adults as having limitations that may prevent that client from fully utilizing the resources and interventions the social worker has to use and may hold back on utilizing them fully.
Clients who are female working with a male social worker may automatically agree with anything the social worker says due to submitting to male authority. Also, male clients working with a female social worker may be uncomfortable with a female authority figure. Social workers do best to point out observations in order to open the door for further conversation and still create a good working relationship.
Clients who are homosexual may believe that since most of society is against same-sex couples that the social worker will judge them for their sexuality as well.
Clients from different racial and/or cultural backgrounds may feel misunderstood if the social worker is not aware of customs that the client practices and implements.

In all of these situations, the social worker would do best to first be self-aware of any judgements that they have themselves and be able to go into sessions/meeting with clients without letting those judgements impact the work that they are doing. Social workers can ask questions about the client's differences at an appropriate time in order to open discussion for their perceptions in a safe and inviting way so that they do not affect the work. Social workers using the code of ethics recognizes that each person has value.

There are also different theories in relevance to social work practice.
The empathetic relationship theory states that the social worker appreciates what someone else is feeling even if the cause is not current. Social worker would need full background information to fully understand the complexities of the feelings/emotions. In order to fully incorporate empathy into the therapeutic relationship, the social worker much be conscious of their own thoughts toward the person or situation. Tune-in before hand in order to be aware of feelings and to prepare for them
The accepting relationship theory is all about the worth and dignity of each human being. This means to accept the client as an individual by showing concern about how they are feeling and coping.
The authentic relationship means that the social worker acts in a way that is open and honest with the client while at the same time not allowing the client to know the judgments that the social worker has. If the client does not believe the social worker's honest, they cannot move forward. It is best for the social worker to be consistent and to present their true personality w/o taking anything that the client says personally. Social workers can admit to mistakes if one occurs and be sure to follow through on promises and agreements.
The power relationship refers to the social worker's expertise gathered through experience, credentialing/education, and involvement in organizations/groups. The client comes to the social worker and gives them power b/c they are willing to change their bx based on Social worker's experience. The social worker then must balance the power and authority that they have and use it dependent upon the situation such as if the social worker has to involve authorities.

Transference/Countertransference
Transference is when a client has thoughts/feelings about the social worker that has been applied to the social worker due to past experiences and situations. These thoughts and feelings can be either positive or negative. However, either way, they hinder the working relationship. It does take longer to work with a client who is experiencing transference b/c they require an extra intervention to help them realize their feelings and where they are coming from.
Countertransference is when the social worker has thoughts or feelings about the client due to past experiences and situations with other clients. It is best in this situation to a) be self aware and b) seek consultation with a peer or supervisor. This way the social worker can gain a 3rd party perspective and help keep themselves on track with viewing this client as an individual.

Psychotropics

There are 5 classifications of psychotropics listed below with the most common/recognizable types next to them. Some of them I have the drug name/trade name while others I only have the most recognizable form of what the drug is called. There are many more but to include them all would be over-extensive I think for the purposes of the exam. I really don't think names will be used at all but knowing the different types will be beneficial for exam plus practice.

Antipsychotic Medications – act in part by blocking dopamine receptors in order to inhibit excitability of the neurons. Typically only addresses the hallucinations and delusions but not the negative symptoms (loss of something whether speech, motivation, etc)

(i)                Conventional: Thorazine, Prolixin, Haldol

(ii)              Atypical (2^nd generation): Clozapine, Ability, Zyprexa, Seroquel, Risperdal, Geodon

Antidepressant Medications - all have anti-anxiety effects as well; Some attempt to increase prevalence of norepinephrine and serotonin. 4 types:

(a)              MAO inhibiters (Monoamine Oxidase Inhibitors): Phenylzine/Nardil, Tranylcypromine/Parnate

(b)              Cyclic Antidepressants – Protriptyline/Vivactil

(c)               Selective Serotonin Reuptake Inhibitors (SSRI): Celexa, Fluoxetine/Prozac, Luvox, Paxil, Zoloft

(d)              Atypical Antidepressants: Bupropion/Wellbutrin, Trazodone/Desyrel, Duloxetine/Cymbalta

Mood-Stabilizing Drugs – for bipolar/mania: Lithium. If someone does not respond to lithium, other medications may be attempted such as Tegretol, Neurontin, Lamictal, Topamax, Depakote. These have higher therapeutic index which makes them more ideal but do not have the same effects.

Anti-Anxiety Medications –

(a)              Benzodiazepines: Xanax, Klonopin, Valium, Ativan

(b)              Buspirone/Buspar

Psychostimulants – mimic action of adrenaline to create mood elevation, alertness, ecompetence (mostly used to treat ADHD): Adderall, Strattera, Ritalin, Concerta

 Bentley K.J. & Walsh, J. (2006). The social worker and psychotropic medication: Toward effective collaboration with mental health clients, families, and providers, 3rd ed.  Brooks/Cole, CA.

Brain Function and Psychotropic Effects

To understand how medications effect the body in both progressive and aversive ways, you have to have a basic understanding of the brain's functions. The parts in bold are ones most commonly affected by medications:

Brain – contains

        (a)              nerve cells (neurons) – carry out all brain functions: thoughts, emotions, behavior.

                (i)                Behavior is changed due to chemistry changes but chemistry changes can occur by complex factors and cellular activities simply by experiencing an event or action

        (b)              glial cells – provides nourishment for neurons and carries away waste products

        (c)                blood vessels-  

Brain sections

       (a)              Hindbrain

(i)                Brain stem – links brain to spinal cord; maintenance of involuntary life support functions with medulla oblongata

(ii)              cerebellum – receives info from muscles and joints and controls bodily functions operating below consciousness (balance, posture, etc)

(iii)            pons – links areas of brain to each other and to central nervous system

(b)              Midbrain – located above brain stem and monitors various sensory functions and is center of visual and auditory stimulation. Collections of cells on upper surface of midbrain relay specific info from sensory organs to higher levels of brain

(c)               Forebrain – largest section of brain

(i)                Limbic System – center of emotions; responsible for maintaining homeostasis of the body (regulating body temp, blood pressure, blood sugar, heart rate)

(a)                Hypothalamus – monitors info from autonomic nervous system and influences body bx

(b)                Thalamus – sensory info from body to brain

(c)                Hippocampus – converts info from short-term to long-term memory

(d)                Cerebrum – largest portion of brain and has highest intellectual levels

(i)                 Frontal Lobes – govern personality, emotion, reasoning and learning, motor control, decision making

(ii)               Temporal lobes – gross motor skills and integration of sensory input (hearing)

(iii)              Parietal lobes – long-term memory and info processing

(iv)              Occipital lobes – visual input

(d)              Other parts of Nervous system:

(i)                Spinal Cord –

(a)                part of autonomic nervous system– regulate unconscious and involuntary activities of internal organs and blood vessels. Has 2 subsystems

(i)                 Sympathetic System which functions when there is an expenditure of energy (such as exercising)

(ii)               Parasympathetic – prominent in body’s buildup of energy reserves (resting)

(b)                Peripheral Nervous System – neurons branching from spinal cord to muscles with messages from central nervous system to control voluntary muscle activity

(i)                 Pyramidal pathways manage fine motor activities

(ii)               extraphyramidal manage gross motor activities

 Messages pass through brain and nervous systems through neurons. Neurons consist of an axon (or axons) which passes messages to cells in the body and dendrites which receive signals from other neurons. They do not touch each other however. They are separated by a small space called a synaptic cleft. Messages are generated by electrical conductivity (nerve impulse). The transmission to a receiving cell is helped by chemical neurotransmitters released by axon into synapse and attaches to specific receivers (receptors) on the dendrite - much like a puzzle. The attachment of this neurotransmitter to the receiving cell creates an impulse along that cell that creates a reaction on the axon end of the neuron. The protein or neurotransmitter is then discarded either as waste through the glial cells or  goes through reuptake where it is released to create more neurotransmitters in the future.

 Finally, how drugs work: Medication modifies the natural processes in the synapses in certain areas of the brain. It alters activity in order to prompt neurotransmitter release or affects the binding of the neurotransmitter to the receptors. It can stop the reuptake process or alters the manufacturing of receptors. In effect, it becomes an agonist that either mimics the neurotransmitter or antagonist in which binds to the receptors but decreasing effect of neurotransmitter.

             Psychotropics tend to affect the following 6 out of 40 neurotransmitters:

(i)                Acetylcholine – affects arousal, attention, memory, motivation, and movement

(ii)              Norepinephrine – created in response to stress or arousal; influences alertness, anxiety, and tension

(iii)            Dopamine – influences emotional bx; cognition; motor activity; lack can cause physical tension, rigidity, movement difficulties (creating parkinsonian effects); regulates endocrine system

(iv)             Serotonin – sensory processes, muscular activity, thinking, calms nervous system, regulates moods; affects appetite, sleep, sexual bx

(v)               Gamma-aminobutyric Acid (GABA) – anxiety & modulation; motor activity, heart reflexes, anxiety

(vi)             Glutamate – researchers think it affects development of mental d/o’s

             Four Bodily Processes:

(i)                Absorption – drug enters bloodstream. Injected medications enter bloodstream more quickly than oral medications

(ii)              Distribution – after entering the bloodstream, the drug travels to the designated area by either dissolving into the plasma or attaching to proteins. Only the unbinded portion of a drug can enter the brain however so dosage is key in providing the right amount

(iii)            Metabolism – body breaks down chemical structure of drug and can be eliminated from body (usually takes place in the liver)

(iv)             Excretion – drug is eliminated from body (lowers concentration in body)

How drugs effect body – drug action is effected by age, weight, sex, and any organ problems or diseases that might interfere with efficiency of how the body handles the drug. Therapeutic index of a drug is the ratio needed to produce the effect wanted by taking the drug compared to the lowest average that produces toxic effects. The more toxicity, the higher risk for negative side effects. A high therapeutic index creates less of a chance that the client will accidently take more and put themselves in danger. Potency is the strength of the drug (dosage) and this is different for all drugs. Dose response is the increase in therapeutic effect with increase in amount but only up to a certain point in which they are ineffective or harmful. Lag time is the time it takes for the medication to start working. Tolerance, much like tolerance in substance dependence, means the body isn’t responding to the same dosage it used to. Adverse effects are the effects of a drug that do not have therapeutic value.

It is important to note the Placebo effect of medication in which a certain percentage of people will have results by just thinking that they are taking medication that will work. This positive thinking creates the results that they want.