Conducting Psychosocial Assessments

As a Social Service Worker student I spent 8 months as a Bereavement and Palliative Care Case Manager with Durham Hospice, an organization that provides counselling, peer support and friendly visiting individually and in group sessions for individuals suffering from life-limiting illnesses (in particular those with less than a year to live) and those who are bereaved.

One task required of that, and an important skill for social workers, social service workers and others in the helping profession is how to perform psychosocial assessments. These assessments give a biographical sketch of an individual and may include areas such as:

• Presenting Problem
• Basic Information
• Family History
• Medical History (including often separate sections for Substance Use and Abuse)
• Support Systems
• Education and Employment
• Spirituality
• Assessment Summary and Next Steps

There are a variety of free structured and semi-structured assessment tools, so no need to re-invent the wheel. Many tools change or modify this sequence, and it should be interpreted as a rough, example outline at best. Most agencies, if a tool doesn’t exist, eventually end up developing their own that covers what they need. For instance, Durham Hospice’s tool incorporated the Bereavement Risk Assessment Tool.

Goals of a Psychosocial Assessment

The goals of a psychosocial assessment is to establish where the client is at the moment of contact (or changes – positive or negative if this is a subsequent assessment) and to determine what services would be most effective to remove the barriers a client is currently experiencing.

Depending on your agency you may be limited in the services that you have at your disposal but it is important to perform a comprehensive evaluation so that you and the client can make decisions with all available information.

Establishing Rapport

The first step to conducting a psychosocial assessment is to establish rapport. This involves any steps you can take to ensure a warm and welcoming environment.

If a person is coming to your office, it’s important to have a confidential area for you to talk, with comfortable chairs and limited distractions. If visiting someone’s home, showing respect for their home is important. Depending on your clients, it may not be safe for you to remove your shoes, but showing that you care about their environment is important.

In either situation, you should speak slowly and with a gentle (but not condescending) voice tone; if your environment permits it, offer them coffee or tea. Your goal is to help the client feel comfortable so that they’re willing to open up to you in what may be a very stressful and scary situation.

Collecting Information

Once you’ve begun the actual interview process, it is important to remember that while you have a need to collect information, you are speaking to a human being. Starting with more lightweight questions allows you to begin learning information about the person’s employment and school status, their physical health, and their family history.

Sections of the Assessment

Presenting Problem

In this section, you describe the problem that initially led the person to seeking out your services. Depending on much information you have this section may not be particularly detailed. For instance, “Mario phoned in seeking housing assistance as he is about to be evicted from his rooming house.”

Basic Information

In this section, you describe the gender, age, marital status, race and ethnicity and living arrangements. For instance, “John is a 32 year-old white male who lives alone in an apartment in [neighbourhood]-area and is not married.” Depending on the cooperation of the client, this information shouldn’t be too difficult.

Family History

In the family history section, you want to describe the client’s family and their relationships with those individuals. Who the person has in their life, and how much of a support they are. If you have their ages, this information can also be included.

For example, “Allison has a good relationship with her mother (51) and father (53). She is an only child. She has one aunt and uncle who she has no relationship with, and little knowledge of her extended family. She expresses no interest in relationships with her extended family but does want to learn about her family tree.”

Medical History

In the medical history section, you can list details about any medical health issues the person is experienced. If they take medication, listing it (and dosages if available) is helpful.

For example, “Lois is diagnosed with Major Depressive Disorder (MDD) and sees a psychiatrist twice monthly. She is currently on Lexapro (escitalopram) 20mg once a day. She also suffers from asthma and has been a smoker since her early teens. Her medication makes her feel bloated and this makes it hard for her to stay compliant with her medication.”

Support Systems

In the support system (or similar) section, you can list any supports that a person has. This can include her friends, family, any other community organizations and so on. Does the client have any hobbies? These are also important to record.

For example, “Lisa has two friends she considers good supports. Additionally, she volunteers for a local charity store to keep busy and has weekly telephone contact with a friendly visiting organization. She enjoys knitting.”

Education and Employment

Sometimes this section is found in one of the others, and sometimes it is separate. You’ll want to describe the job title, industry, organization (if available) of a person’s employment. Additionally, make sure you describe the permanence (or lack thereof.)

With regards to education, note the type of qualification, school and major/program, and what a person hopes to do with it. An example is below:

“Sarah works part-time as a cashier at a grocery store. This work pays minimum wage and is permanent; her work is not threatened in the near future. She is a full-time student in a two-year Veterinary Technician program and hopes to seek employment in that field after her graduation next year.”

Spirituality

A person’s religion may be a very strong factor in their life, but for others it may not come up. At Hospice, because of the potential for dying soon, spirituality was likely a more important element in our clients than in many organizations. You’ll want to record a person’s religion (if present), their degree of involvement in the organization and any other thoughts.

For instance, “James is a devout Catholic who attends Mass every week. He has a strong relationship with the Church and with his local clergy. He finds the Church a strong source of emotional support.”

Assessment Summary and Next Steps

In this section, you’ll want to record your overall impressions of the client and what services you think are most helpful for the client. This section will likely be the least standardized because it is most dependent on the services your agency actually provides.

Conducting psychosocial assessments is an important skill for every person in the social services to learn, and I recommend every social worker or social service worker spend time performing them under supervision so they can develop this core competency.