MSW 551 ( DISCUSSION )Module 3: Biopsychosocial Assessment, Global Style

Module 3: Biopsychosocial Assessment, Global Style

Introduction W e h a v e t o r e m e m b e r t h a t w h a t w e o b s e r v e i s n o t n a t u r e h e r s e l f , b u t n a t u r e e x p o s e d t o o u r m e t h o d o f q u e s t i o n i n g .

— W e r n e r H e i s e n b e r g , q u a n t u m p h y s i c i s t

What do we mean when we talk about assessment? The word conjures up a subject and an object. The subject is the social worker, the person doing the “assessing.” The object is the client, the one (or two, three or four) being “assessed.” Yet, in a sense, the opposite is true. The client is the subject, the protagonist of their story. It is the clients’ lives that matter. The social worker, to the client, is the object, the other with whom they have yet to form much of a relationship. The social worker is not placing the client under a microscope. Instead, the social worker is inviting the client to climb a hill, from which to look out on life lived, living, and yet to be lived. And the point of all this? To see and map a way forward, a path toward a viable, meaningful future that fits with the client’s own values, capabilities, and situational limits and possibilities. Global awareness in the context of assessment means seeing your clients, and helping them see themselves, in the larger landscape of intersecting identities, historical forces, and cultural values. Let’s give this a try with a current client of yours.

Practice Exercise

Reflection

Take the following steps after you read through all of them. Close your eyes, take a couple of deep, cleansing breaths, and picture an individual, couple, or family you have been working with at your practicum site, meeting with you in the usual setting. Remember how they look, what emotions they communicate or try not to communicate, some of the things they have said to you. Now make a mental list, as exhaustive as possible, of all the different sources of information from this client that go into forming an assessment.

You can also use the textbox below the instructions to list all the sources of information you can think of. Once you have completed your list, open the hidden list below and see how it compares.

Maybe you are missing some data sources because you forgot them; maybe there are some you never would have considered. Others may be unavailable or irrelevant, and you may have thought of still others that should be on the list. Don’t expect yourself to

ask about everything on the list – that would be overwhelming both for you and your clients!

Your list of information sources for family assessment:

Sources of Information for Biopsychosocial Assessment Within each category on the list are many examples. Click on each category to reveal them.

Observation

• Dress, tattoos, etc. • Hygiene & condition of clothes • Body language – eye contact, gestures, character armor • Health and mobility • Proxemics with you • Proxemics with each other • Speech patterns • Language barriers • Thought processes • Cognitive impairments • Intellectual strengths

Family History

• Migration and acculturation • Spiritual/cultural beliefs and traditions • History of violence and legal issues • Intersecting identities • Mental illness • Intergenerational trauma • Substance use • Physical illness and death • Mental/physical disability • Educational attainment • Vocational experiences • Military experiences

Family Structure

• Partnerships and separations • Births, miscarriages, abortions, fertility, adoptions • Multigenerational families • Blended families • Single parent families • Enmeshment, conflict, distance

• Current abuse or neglect • Mutually supportive relationships • Developmental stages of children • Developmental stages of adults • Roles of family members • Family rules and boundaries

Socioeconomic

• Housing conditions • Neighborhood conditions • Environmental risks • Access to nature • Access to food • Financial stress • Financial management • Access to government support • Access to informal support • Unfulfilled aspirations • Local, national, and global economic trends

Presenting Problem

• Nature of suffering • Connection to values • Frequency, duration, and intensity • Consequences for each family member • Proximal causes • Distal causes • Maladaptive solutions • Safety concerns • Adaptive solutions

Archival Information

• Referral • School records • Employment records • Medical records • Mental health records • Legal records • Financial records • Behavior logs • Diaries

In the next section, we’ll go beyond the “what” part of assessment to the “how.”

Assessment: From Content to Process We should continually consider more sources of information as we get to know our clients, but all assessment is a balance between what the client is already focused on, and what we might consider relevant that they have yet to consider. Instead of being overly structured and peppering our clients with questions, we can often use silence, encouraging nods, and broad questions like, "Can you tell me more about that?" to elicit much of the information we need. Your agency probably has its own intake form, and sometimes you may feel obligated to be highly structured in order to complete it. One way to humanize this process is to explain it first. And before that, it can be helpful to give the client a chance to talk about what brought them to you. From there, you can provide transitions between topics so that the client understands that everything you are asking is designed to help them, not just help you fill out a form.

Examples of transitions:

I appreciate that it took courage to share these things with me. To understand better how to help you, I want to ask you some questions about past experiences with mental health treatment. Is that okay?

You talked earlier about how important your grandmother was to you growing up. Can you tell me about your current relationships? Who is important to you, and are there any problems in your relationships with family members?

Before we go on to talk about the ways I can help you, I want to make sure there are no immediate safety concerns. You seemed pretty nervous when talking about your boyfriend. Has he ever said or done anything that made you feel unsafe?

Another metaphor (in addition to climbing a hill together) that can be helpful here is as shown in this image:

A metaphor that can be helpful as we ask clients to talk about intimate aspects of their lives is that of visiting their home. The outside of the home represents what you can see at first glance, the appearance they seek to convey to the public. The living room is where they entertain guests. It represents the explanation clients give to others for what’s going on in their lives. The kitchen is where the action happens – the dynamics you observe among family members. The bedrooms are the more private lives of clients – the fears and dreams they only reveal to those whom they trust. The closets are where the actual secrets are hidden, the experiences and behaviors that bring up powerful feelings of shame or fear of punishment. The attic contains the family history, the remembered and forgotten stories and memories that still live within the clients and affect their lives today. And the basement holds the unconscious stuff. Not even the client knows what’s in there, but the right questions can lead to important discoveries.

The important point here is that no client will reveal or is capable of revealing the whole home at once. Consider yourself privileged to be invited into the living room on your first visit. Remember in subsequent visits to be alert for unexplored rooms or information in

those rooms. Many experienced social workers can tell you about information that was gained long into a helping relationship that cast the client in a whole new light. The wife of a man in inpatient hospice discovered, when she had to search through his military records for information relevant to his current diagnosis, that much of what he told her about his military career was fabricated. Therapy shifted from preparing for death to finally telling the truth about himself. Why had he lied to his wife all these years? Because he never felt that he was good enough. He was the scapegoat in his family of origin and had learned early on to lie about himself to get others to respect him. The longer he told the lies, the harder it would have been to tell the truth. Yet in his decision to finally be honest and to genuinely apologize to his wife for the harm his deception had caused her, he achieved a legitimate pride in himself he had never experienced before.

One more note on honesty in the assessment process: individual and families differ in the ways they reveal truths about themselves. Individuals often share information more readily, because they feel relieved at being able to confide in someone who won’t judge them or share their secrets. But whatever they conceal from themselves, they will usually conceal from you. On the other hand, family members often edit what they say in front of each other. They aren’t ready, at least at first, to open up on potentially explosive topics. However, families can’t help but show you the truth of how they interact. Some are skillful at presenting a polite version of their dynamics, but this will break down as you explore the presenting problems. In other words, individuals tell more, and families show more.

How is Assessment a Form of Intervention?

Practice Exercise

As a graduate student, the author was once administering a structured clinical interview to a new client at the university community mental health clinic. She was middle-aged and lived with her domineering sister. To almost every question she answered, “Well, my sister thinks…” or “I have such-and-such a problem, my sister is always telling me.” To each of these statements, the author asked some variation of, “Okay, that’s what your sister believes. What do you think?” Toward the end of the interview, the new client looked directly at the author and said, “You know, I feel like this has already helped. I never realized I had my own opinions about myself that were different from my sister’s!”

This is a poignant example, but in less obvious ways, we have always already begun intervention when we are assessing the client’s problems. How? Click on each button below to learn more.

Increasing self-understanding As clients hear themselves talk about their problems, they gain insight and often develop more compassion for themselves.

Connecting the problem to the context As clients see that their problems are not so much evidence of being bad or defective, as being part of societal forces, they feel more worthy.

In reasons lie hope When clients see how their problems came about, they can also see that solutions are possible. They go from being victims to problem-solvers.

Confession is good for the soul Part of the suffering from psychosocial problems is the shame one feels and the fear of being judged. When problems are shared and understood, some shame dissolves.

Having an ally Part of what can be so demoralizing about problems is having to fight them alone. Just knowing that someone is going to provide support feels much less overwhelming.

I’m not the only one During the assessment process problems are often normalized as a common and expectable reaction to an overwhelming stressor. Realizing that others suffer in the same way means one is neither crazy nor alone.

Assessment and Healing When we explore intervention beginning in Week 5, we will take a close look at Testimony Therapy, an approach adapted from narrative trauma work, to working from an Afrocentric perspective with individuals and families. Akinyela (2008) describes the Four Healing Questions that both engage clients in the assessment process and set the stage for intervention. They are:

What happened to you? How does what happened to you affect you today?

What has given you the strength to carry on? What do you need to heal?

Notice the focus of each question. By focusing on what happened, the first question locates client problems in a larger context and gives space to tell the story. By connecting past events and present realities, the second question help the client to make sense of their suffering through the creation of their own meanings. By asking about strengths, the third question engages the client in identifying their resilience and their cultural resources. And by naming the process "healing," the fourth question invites the client to know that a wounding has happened, to know that healing is possible, to shift from looking at only past and present to an imagined future, and to consider not

only internal resources, but needs that could be met by the social, spiritual, and natural environments.

Summary We hope that by examining the content, process, and benefits of assessment, you can see into its ongoing nature and the importance of seeing it as interwoven with the engagement and intervention process. We have provided some metaphors for assessment, some guiding questions, and some sources of information to consider. At the heart of all these aspects of assessment is decentering: placing oneself at the margins and the clients at the center, seeing the assessment process through their eyes as much as possible. To do so as a student means to manage your anxiety about getting enough information as you also work to establish rapport and meet the clients' need to alleviate suffering. We will explore this topic further next week as we expand our focus to assessing the needs, strengths, goals, and dynamics of groups, communities, and organizations.

References Akinyela, M. (2008). Once they come: Testimony therapy and healing questions for African

American couples. In McGoldrick (Ed.), Re-visioning family therapy: Race, culture, and gender in clinical practice, 2nd Ed. Guilford Press.