Real World Clinical Blog: Assessing Through a Kaleidoscope (Part 2)

by Dr. Danna Bodenheimer, LCSW. author of Real World Clinical Social Work: Find Your Voice and Find Your Way

 (Editor's Note: Read Part 1 here.)

    Last week, I wrote about the need for assessment to be an integral and ongoing piece of the overall treatment process. Thinking of assessment as dichotomously distinct from treatment relegates our period of inquiry to early sessions. It also leaves us hastily conclusive. Of course, the pressure to assess early is to produce a diagnosis for a client. These diagnoses are often used for immediate billing and to create a shared language within an agency about a client. For example, if we label a client as having schizoaffective disorder, then we can all agree about some of the primary traits of that client. Supposedly.

     Before delving deeper into what can strengthen the assessment process, I think it is worth reflecting on the insanity of the pressure to ever come up with a diagnosis based on 45-50 minutes with someone. Sure, some intakes last longer - but certainly not long enough to label long-standing patterns of behavior, coping mechanisms, and defensive functioning.

     Given that this expectation makes no sense in our effort to understand complex human functioning, it is fair to internally reconstruct our assessment process and to go with what feels most ethically right and dignified. I know that a lot of what I write about defies agency culture and expectations. My hope is not to describe anything that feels impossible or undoable for social workers. Instead, I am hoping that you find ways of interacting and assessing your clients that are more suited to your internal values, than to agency standards. Dealing with the ensuing discrepancy that will come from this demands hard work and utter creativity.

     That said, the more that assessment and intervention can be integrated, the more likely we are to create a well attuned intervention strategy that is based on our clients’ unfolding life stories. To work with real people, we need to be flexible in our perceptions and in our treatment strategies. The best way to do this is to constantly check in with a client about how the assessment process is going. Perhaps they have an idea about what would help more. I think we often forget that our best supervisors are our clients.  The more information that we seek from our clients, the more effectively we can treat them.

     Holding firm to the idea that one of our central assessment tools must be our authentic curiosity, here are some other areas that I try to learn more about when working on creating a treatment relationship.

What is your relationship with food like?

     We often only think to inquire about someone’s relationship with food when they are presenting with a traditionally identified eating disorder. In doing this, we miss a tremendous amount of information about non-diagnosable food relationships. Everyone has a relationship with food. There is no exception to that rule. Some people have a more complex relationship with food than others do. We often have the assumption that cis-gendered women struggle with food more than cis-gendered men. This negates a lot of truth about the male struggle with food. It also negates the unique struggle with food that exists for trans folks.

     We often think that food struggles are limited to more privileged populations. This is also a dangerous misperception. Many food issues are born out of food insecurity and fears around scarcity. We need to give space for clients who felt that they had too much food. We also need to give space to clients who feel that they never had enough. We need to hold onto the very real truth that food often acts as a metaphor in the psyche of clients. In the food relationship, we can identify feelings about being “too much,” “never enough,” and fears about insatiability and desire. Food themes are often life themes. And the discovery of life themes is far more important than any diagnosis.

What is your relationship with alcohol and/or drugs like?

     Similar to food, we often assess for drug and alcohol issues when there is a stated problem. Most people, again, have some sort of a relationship with drugs and alcohol that holds important clinical data. Our questions ought not be limited to an excess use of substances. Instead, we can open a dialogue about the role that substances play in the home, in one’s sex life, socially, and financially. We should also dedicate curiosity to the role of substances in one’s family. If someone has had a loss that was due to overdose, their drug use holds specific meaning. I am eager to widen the conversation about substance use away from simply assessing for abuse. Instead, let’s consider discussing the meaningful role that substances play in many lives.

Describe your block to me.

     If we can’t picture the home that someone returns to daily, we are definitely missing something. As social workers, we are intensely interested in environment and the ways in which environment affects the psyche, although we are often remiss in our efforts to truly understand the texture of one’s individual environment. If someone lives in a row home, I am curious about the neighbors. Do they talk to them? Do they live amongst family? Is the house next to them abandoned? If someone lives in a homeless shelter, I am interested in how the bed feels, how safe their belongings are, how many people are all falling asleep in the same room. If someone is in a neighborhood that they have been in for generations and it is becoming gentrified, I am interested in the presence or absence of grief around that. Is there a neighborhood grocery store? Do they hear gunshots at night? Is the walk to school safe? The list goes on. The central point is to learn enough to get a visual representation of one’s neighborhood, so we can better understand the underlying stressors of one’s daily life and we deepen our attempt to witness them.

How do you feel about your educational history?

     There are feelings of pride, shame, disgust, terror, sadness,and  triumph tied to educational experience. Some clients have graduated from Harvard Law School and still don’t’ feel a sense of accomplishment. Other clients have not completed high school and are constantly hiding something about their sense of their own intellect. Many people have had great educations and are now drowning in student loan debt. Some people are continuing a family tradition of education, and others are terrified as they break the mold. Education in our country is a commodity and a piece of social capital. There is a lot of identity tied up in education that we often forget to talk about, because it  is not a traditional area of clinical inquiry. In my experience, the study of one’s educational history leads us to understand the person's psychological experience of this history.

How would you describe your family of origin’s parenting style?

     First, it is important to note that not all of our clients have had parents in their lives. I think it is worth asking someone about who they identify as their family members. These can be friends, foster parents, grandparents. We can not assume the presence of a traditional nuclear family structure. However, whoever raised someone had a style of parenting or caretaking. The traditional styles are authoritarian, authoritative, and permissive.

     I am not really talking about that. Instead, I want to know if a family was boundaried, close, distant, enmeshed, chaotic, stable, rigidly married to routine, able to talk about difficult topics, overstimulatingly open, or parentifying. The list goes on. I am even curious about whether or not there were locks on the bathroom doors and if these locks were used. I am not interested in judging the answer - just making sense of it. Although it may seem like an inane level of detail, all of this matters. It matters because this information provides us with clues to the endlessly intricate puzzle of one’s mind.

How would you describe your relationship with your body?

     While the food topic might seem to cover the issue of one’s body, it certainly does not. Of course, all of our clients have bodies. Part of where treatment falls short is in the misconception that we are healing minds, which are somehow separate from bodies. Working from a holistic, social work perspective, we must endlessly respect the interplay between one’s mind and body. There is, in fact, no real difference between the two. Some people feel strong in their bodies, while others are sure that their bodies will betray them by illness or injury. Some people feel completely imprisoned by their bodies because of past abuse and the resulting symptoms.

     I like to ask people what their relationship with their body is. I am always curious about the answer. Even in asking the question, we acknowledge - amelioratively - the sheer presence and fact of one’s body. We disabuse them of the notion that they are invisible to us. This can be difficult, because invisibility can sometimes feel better than visibility. This is worth talking about. This is essential clinical data. If our psyches become injured, the scars reside in the body. We honor this truth by acknowledging this truth.

Intergenerational patterns

     Some of the most subtle and abstract patterns of functioning that people deal with are the byproduct of intergenerational patterns of trauma and functioning. It can be incredibly useful to ask about struggles of past generations that clients are still aware of. For example, having ancestors who were part of the Holocaust or slave trade can have a lingering impact on the psyche today. Another example is to think about the intergenerational impact of immigration. Perhaps someone’s parents or grandparents never learned to speak English, and the client largely serves as a translator today. This is of terrific psychological impact and ought to be introduced into any therapeutic dialogue.

Cultural, ethnic, racial identity

     Obviously, we, as social workers, are concerned and mindful of the impact of oppression and difference. While no one has really achieved a level of expertise around how to discuss difference, that does not mean that we can leave it out of our clinical discourse. It is essential to ask about someone’s sense of who they are. A client’s external appearance might be aligned with their sense of self. However, the more invisible differences are the ones that need utterance in the presence of another. We know that identity plays a central role in how someone functions in the world. The question for us is: how? How does it feel to be biracial? How does it feel to be queer in a conservative community? How does it feel to be the only African American student in a class of white students? It is not just how someone identifies, it is about how that identity is experienced.

We need to ask

     Our questions need to be crafted in a way that they don’t feel intrusive, don’t feel assumptive, and don’t feel rote. This is actual artistry. In fact, one of our biggest tools is the art of asking questions - very good questions. It is ultimately our work to help clients give voice to their internal worlds. It is only with attuned, empathic curiosity about the minor and major details of someone’s life that this voice can be heard.

Dr. Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. She is the author of Real World Clinical Social Work: Find Your Voice and Find Your Way.