Questions
by Dr. Danna Bodenheimer, LCSW. author of Real World Clinical Social Work: Find Your Voice and Find Your Way
I often marvel at the gap between what an intake form asks us to discover about a client and what it is that we actually need to know. Although there isn’t a standard intake form, agencies basically strive to collect some similar information. The questions typically include a study of the history of the presenting problem, current stressors, drug and alcohol history, trauma history, financial stressors, perhaps some family and relationship history, maybe legal issues, and a sense of overall social functioning. All of these topics are of terrific import, but I am not sure that they support the depth of the relationships and conversations that social workers ought to be constructing.
While I am not encouraging everyone to suddenly go off script, I do want to think about what pieces of information might really serve to create an in-depth assessment, thereby creating more highly attuned interventions, clinical relationships, and treatment.
Let’s start by talking about why a social work assessment is different from any other...or at least why it should be. The founding principles of social work are that we treat the whole person; that we see the person as a central part of the environment and the environment as a central part of the person; that we take race and socioeconomics intensely seriously; and that we pay vigilant attention to development, attachment, and trauma. In order for us to attend to these principles, we need to create a way of thinking about and performing assessment that honors them.
Further, when assessment is done well, it is a performance of true curiosity. We demonstrate to our clients that we are deeply interested in who they are and want to know about the major events in their life as much as we want to know about the nuanced texture of their daily functioning. Curiosity, unto itself, is curative. We often forget that assessment is actually an intervention on its own, if it is done well. Just think about how it feels when someone really asks you how you are doing, how your family is doing, and what you are stressed out about. The questions make you feel held and seen. The questions make you feel like you matter. Assessment, when done well, is an intervention.
How can we make it a truly powerful intervention? When I meet with someone, I have a lot that I want to know. In fact, I truly let my curiosity take over. If I am to sincerely surrender to my curiosity, rather than some pressure to assess “right,” I find that my ability to assess is strengthened. When I don’t rush through an assessment or think about what is on an intake form, I also find that my assessment is strengthened.
Here are some areas of true curiosity for me that I think echo our field’s founding principles.
Past experiences with social workers
For any good assessment to take place, we need to get a good handle on the potential transference themes that might come up. We often think of transference as the placement of past familial dynamics onto clinical dynamics. That is certainly a central part of it. However, transference can also take a simpler form. Clients who have had negative experiences with social workers will be less open to new experiences with social workers. Clients who have only worked with interns will be less likely to confidently attach if their intern left in the middle of a good treatment alliance. We need to understand a client’s attachment history to our field to get a sense of how they might be internalizing and preparing for their work with us.
We need to ask about it.
Birth story
I am almost always interested in someone’s birth story. A birth story is a narrative told between generations. We rarely know if the information in a birth story is true or false, but we must pay real tribute to the power of the narrative. I have clients who don’t know their birth story. That is powerful information. I have clients who have birth stories that literally make no sense. That is powerful information. I have clients who say that their mother almost died during labor. That is powerful information. I also have clients who say that they almost died in birth. That is powerful information. There is no piece of information in a birth story that is irrelevant. It can almost all be considered symbolic and representative of larger life themes. If someone doesn’t know anything about their birth, that means a lot about their access to information about their past. Perhaps they were adopted. Perhaps their mother was not conscious. Perhaps they are the youngest of 12 kids. No matter what, the data in a birth story is worthy clinical content.
We need to ask about it.
The history of their name
Every client’s name has meaning. Perhaps they were named after their mother’s favorite soap opera character (this actually happens a lot), or perhaps they were named after their great grandmother who died in the Holocaust. Held in a name is a story about how someone’s life was imagined from the minute they were born. Perhaps there was a hope that they would fill a hole left by someone who died suddenly. Perhaps there was a hope that they would become the next president. I had an African American client who was named something that many white children are named. Her parents called it a “résumé name.” I have another client who was named after her mother’s best friend who died in a car accident. Her mother always hoped that she and her daughter would be best friends. She hoped that they would spend many days doing activities similar to what she had done with her friend. When her daughter didn’t have this interest, her mother’s disappointment was complicated by grief. There is a story in every name. With every story, our assessment grows deeper.
We need to ask about it.
Attachment patterns
I always ask about a client’s perception of their family’s attachment patterns. Was there affection in their house? How often do they check in by phone? How old were they when they were first left alone? What does 7 p.m. in your home look like? Is everyone together on a couch watching TV? Is everyone in separate rooms? Did you eat dinner together? Are some people hungry while others are full? Was there enough food for the night? All of these questions bring you more closely into someone’s reality. In doing that, we have a better sense of how their family attached to each other. Attachment patterns are almost always intergenerational, unless they are shifted by some confounding, healing, or hurting variable. For example, someone could have grown up in an extremely avoidantly attached family but went to a very loving school. Another could have grown up in a very securely attached family but suffered tremendous trauma. No matter what, patterns and disruptions in attachment are worthy of examination in assessing a client.
We need to ask about it.
Gender and sexuality
Issues of gender and sexuality are never simple. If you have a trans client who once identified as gay and now identifies as straight, there is a tremendous amount of data to collect around the client's internal experience of this. If you have a cis-gendered straight client, there is tremendous information to be collected about that experience, too. No one has a simple experience of their gender or their sexuality. I am cis-gendered, and I know that performing femininity feels complicated to me. I have many trans clients for whom the case is the same. I urge you to consider that everyone is having an experience of their gender and sexuality that is worthy of bringing into the clinical relationship. I also urge you to recognize the interconnected relationship between gender and sexuality. For those who don’t feel comfortably seated within their gender, sexuality becomes much more complicated. For those who don’t feel comfortably seated within their sexuality, gender becomes much more complicated.
We need to ask about it.
The bank account/The absence of the bank account
Every client, every client, every client, has a complicated relationship with money. We are often told (outside of the field) to never really talk about money. Of course, the top three stressors in most conversations are traditionally considered to be: politics, religion, and money. We cannot let this sense of taboo keep us from allowing our clients to share their money stories. Perhaps we have clients who feel overwhelmed and ashamed by their privilege. This is information that might literally never be discussed if we don’t inquire about it. More commonly, of course, we have clients who feel overwhelmed and ashamed by their poverty and struggle. They would never even want us to know about the depth of their shame and fear.
Think about how you feel when your cell phone rings and it is an 800 number that you have come to recognize as one of your many, confusing student loan lenders. You hit ignore, have a rush of adrenaline, and move on with your day until they call again tomorrow and you do it all over again. Many of our clients get these calls 20-30 times a day, if they can even keep a phone number over time. Many can’t do that. This is information we need to have to understand the utter complexity of their daily stress and anxiety. We can’t just say that they should think differently about their anxiety and pathologize their symptomology without having a behind-the-scenes view of how desperate their moment-by-moment financial struggle is.
We need to ask about it.
Next week, I will write more about creating more intricate assessment strategies and the role that our curiosity about the minutiae of our clients’ lives can play in their ultimate movement toward wellness.
(Editor's Note: Read Part 2 here,)
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.