Module 3: Biopsychosocial Assessment, Global
Style
Introduction
We have to remember that what we observe is not nature herself,
but nature expo sed to our method of questioning.
— Werner Heisenberg, quantum physicist
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.
