Post an explanation of how you might apply knowledge of human behavior and the social environment when engaging, assessing, and intervening with Ray as a social worker.

SOCIAL WORK PRACTICE & SKILL

Author Laura Gale, LCSW

Cinahl Information Systems, Glendale, CA

Reviewer Jessica Therivel, LMSW-IPR

Cinahl Information Systems, Glendale, CA

Editor Sharon Richman, DHSc, MSPT, PT

Cinahl Information Systems, Glendale, CA

February 18, 2022

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2022, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Biopsychosocial-Spiritual Assessment: an Overview

What is Biopsychosocial-spiritual Assessment? › The social work profession is unique among healthcare disciplines in its emphasis on

assessing and treating the client from a person-in-environmentperspective, meaning that social workers conceptualize the client and his or her physical and mental health needs as existing within a social context. The social worker not only looks at psychological or physical needs but also assesses how the client is affected by his or her environment and how the client’s spirituality influences his or her overall sense of well-being.Spirituality can be defined as one’s religious beliefs and practices as well as one’s sense of purpose and meaning in life. As the term indicates, a biopsychosocial-spiritual assessment evaluates the client in four domains: biological, psychological, social, and spiritual (Lacks & Lamson, 2018). This assessment is both the process of gathering information about these domains and their interconnectedness and a written document that is used to determine treatment goals and objectives for the client • What: Biopsychosocial-spiritual assessment is a holistic approach to understanding

the client’s experiences, including his or her physical and mental health (Khalid & Naz, 2020). The biopsychosocial-spiritual assessment is the primary means used by the social worker to evaluate a client’s treatment needs. It consists of a variety of activities and processes used to gather information about a client’s current circumstances, needs, risk and protective factors, and the environmental context within which these elements exist. These elements are organized into a written document, which is used to determine treatment goals and objectives. In mental health settings, the biopsychosocial-spiritual assessment is also used to help determine the mental health diagnosis for the client. While the specifics of each assessment will vary based on the client’s age and challenges, a biopsychosocial-spiritualassessment will always include information from all four domains

• How: A biopsychosocial-spiritual assessment is completed through observation and clinical interviews, standardized screening tools, and review of existing records. The sources of information vary according to the client’s age, circumstances, and problems. Informants may include the client, his or her family members, other individuals determined to be significant by the client, and other professionals who have worked with the client in the past or are currently working with him or her. Because the client’s perspective on his or her needs and resources can differ substantially from the professional’s perspective, the client is included in the biopsychosocial-spiritual assessment and is the key provider of information. Consistent with the value placed by the social work profession on client self-determination, a biopsychosocial-spiritual assessment is a collaborative process between the social worker and the client. Biopsychosocial-spiritualassessments are initially completed at the time of intake (or over the first several sessions with the client). However, the content of the assessment is continually reevaluated as the client’s physical, psychological, social, and spiritual needs and resources change and as new information arises throughout the course of treatment

• Where: A biopsychosocial-spiritual assessment can take place in any setting, including inpatient or outpatient clinics, healthcare facilities, the client’s home, or other community settings. A social worker will often choose to conduct a biopsychosocial-spiritual assessment in multiple settings in order to observe the client’s interactions, relationships, and behaviors in a variety of contexts

• Who: Biopsychosocial-spiritual assessments are used by social workers as a primary means of assessment. However, other clinicians, including physicians and nurses, also incorporate aspects of the biopsychosocial-spiritual assessment into their practice. Biopsychosocial-spiritual assessments are used to assess all clients, including children, adolescents, adults, older adults, and families

What is the Desired Outcome of a Biopsychosocial-spiritual Assessment? › The desired outcome of a biopsychosocial-spiritual assessment is a complete understanding of the complex interactions

that take place between the biological, psychological, social, and spiritual domains of a client’s life. A thorough and accurate biopsychosocial-spiritual assessment will determine the best course of treatment and identify specific treatment goals and interventions that are most appropriate for the client. This will result in a higher likelihood of resolution of the client’s concerns. Through the social worker’s development of a complete understanding of the client in the collaborative biopsychosocial-spiritual assessment process, the client will feel fully understood by the social worker, which will result in the development of trust and a therapeutic working relationship between the client and the social worker and an increased utilization of services by the client

Why Are Biopsychosocial-spiritual Assessments Important? › Social workers are usually employed by social institutions such as hospitals, correctional facilities, and child welfare

departments. Even social workers who work in private practice settings come into contact with social institutions as they help their clients navigate their social environments. Therefore it is critically important to understand how these institutions impact the client and how the client interacts with them. The emphasis of the biopsychosocial-spiritual assessment on the interaction of the client and his or her environment helps the social worker understand this dynamic and any barriers to services provided by these institutions that clients might experience

Facts and Figures › Studies illustrate the complexities of the interactions between the physical (i.e., biological), psychological, social, and

spiritual aspects of the client’s lived experience and the need to assess and intervene in all four domains • Quality of life is higher for persons with paraplegia when they a have strong sense of spiritual well-being (Finocchiaro et

al., 2014) • Persons with schizophrenia have more chronic health conditions than persons without schizophrenia, including congestive

heart failure, COPD, and hypothyroidism. They also have higher rates of dementia than those without schizophrenia (Hendrie et al., 2014)

• Risk for obesity and type 2 diabetes mellitus is higher for older women living in disadvantaged neighborhoods. Researchers found that as neighborhood characteristics improve, body mass decreases (Corriere et al., 2014). Neighborhood characteristics also influence depressive symptoms. Investigators for a separate study found that study participants with type 2 diabetes who lived in neighborhoods that were more affluent, had more residential stability, and whose residents had higher levels of education and professional occupations had fewer depressive symptoms than participants with type 2 diabetes who lived in less advantaged neighborhoods (O’Donnell et al., 2015)

• Exposure to complex trauma, particularly during early childhood, impacts the architecture of the developing brain and adversely affects children’s developmental trajectories, altering their biological, psychological, cognitive, and social development (John et al., 2019)

• Researchers have found that social support is linked with spiritual well-being and better health outcomes in institutionalized older adults (Chen et al., 2017)

• Researchers studying the impact of social relationships on health found that social integration (particularly social connections in adolescence and social support in older adulthood) was associated with lower risk of physical dysregulation (Yang et al., 2016)

• Researchers examined the inverse association between spirituality and depression and found that spirituality can help improve symptoms of depression and serve as a protective factor against suicidal ideation. Persons who considered themselves spiritual tended to be more optimistic and willing to forgive others, which improves self-efficacy and the ability to cope with difficult situations (Portnoff et al., 2017)

• Researchers studying the impact of stress on healthcare students’ ability to perform academically and clinically found that using a biopsychosocial-spiritual approach to self-care improved mindfulness and self-compassion and diminished anxiety, depression, and stress (Klawonn et al., 2019)

What You Need to Know Before Proceeding with a Biopsychosocial-spiritual Assessment › In order to understand the complexities of the interactions between the four domains, information for

a biopsychosocial-spiritual assessment should come from a variety of sources. Before completing a biopsychosocial-spiritualassessment, the social worker should be aware of the types of sources available and what information can be obtained from each. These sources include • A review of client case records

–Review of the client’s medical and/or mental health records can assist the social worker in understanding current and past medical or mental health concerns, medications, and compliance with treatments. It will also provide information on past treatments that have been successful and give the social worker an idea of what risk factors to assess for (e.g., suicidal ideation, self-harming behavior, psychosis, aggression). It can also help the social worker develop a historical timeline of the overall course of the client’s medical or mental health needs. For a child, adolescent, or student client, a review of academic records such as grades and behavior reports is needed. This provides information about the student’s academic strengths and challenges. For children and adolescents in special education, a review of the student’s individualized education program (IEP) is needed. An IEP is an individualized learning plan that outlines the student’s learning disabilities and sets academic goals and objectives for the student for the coming academic year. An IEP can provide information about how the student’s learning disabilities affect his or her academic success and outlines interventions that the school has used to support his or her learning needs. For students with receptive or expressive language difficulties, a review of the IEP can assist the social worker in understanding how to best communicate with the child in treatment and how he or she experiences and interacts with others. The drawback of using record review as a source of information is that records tend to be deficits-based instead of strengths-based. Rather than focusing on client strengths and resiliencies, they focus on the client’s needs. Care should be taken to give as much weight to other sources of information such as client interviews and observations of the client in his or her environment in order to prevent social worker bias and failure to recognize the client’s strengths and competencies

• Verbal report from the client –All biopsychosocial-spiritual assessments should include an interview with the client. The value placed in social work

on client self-determination dictates that clients should be involved in all aspects of their treatment to the extent of their ability. In fact, the primary source of information for the biopsychosocial-spiritual assessment should be the client him- or herself. The client’s own perspective on his or her needs and strengths may be very different from those held by social workers or other professionals. Understanding the client’s perspective is critically important in order to develop goals that are consistent with the client’s concerns. Client interviews can provide the social worker with factual information such as identifying information, problems, historical information, cultural information, and spirituality. However, a skilled interviewer will also be able to elicit more personal information from the client, such as his or her perception of his or her relationships with others, interactions with the systems that are present within his or her life, his or her sense of safety and belonging in the community, and how he or she finds a sense of purpose and meaning in life

–Adolescents should participate in their own biopsychosocial-spiritual assessment. Adolescence is a key stage of growth and development, in which the individual begins to form his or her own identity and develop personal and environmental resources that will help him or her navigate the transition to adulthood. Understanding the adolescent’s own perception of his or her mastery of these transitions and his or her needs and strengths is important to developing an understanding of the client within his or her environment. Interviews with adolescents can be facilitated by encouraging the client to share media content (e.g., music lyrics, movies) that he or she feels relates to his or her own experiences and by encouraging the client to share his or her interests and discuss peer and family relationships

–Even very young clients can participate in direct client interview. For young children, gathering of verbal information may be assisted by the use of play-therapytechniques. Play is the primary way in which children learn about the world and make sense of their experiences. The social worker can use objects and toys that facilitate storytelling, such as puppets and dollhouses, and art therapy techniques to help the child communicate his or her feelings, challenges, and experiences. Young children who have developed verbal skills will be able to provide information on their basic emotional state (e.g., happy, sad, mad) and basic information about their fears and interests. Because young children experience and understand their environment very differently from adults, this direct client information is critical to understanding the biopsychosocial-spiritual needs of the young client. The young child’s perception of why he or she is being seen by the social worker is a critical starting point for building a therapeutic relationship with the child and should be determined during the assessment process

–Direct interview of older adults can give the social worker a sense of the senior’s cognitive abilities. Older adults can often provide rich historical information about their lives and often have a strong sense of spirituality or purpose, which can be identified as a source of spiritual and psychological strength for the client

–When working with families, individual interviews with each family member as well as a group interview with all members are necessary. In addition, the social worker may wish to interview dyads, such as the parents or caregivers together, or specific sibling sets. In this way the social worker can gather information about the strengths and needs of each family member, as well as the family as a whole. Conducting multiple types of interviews with client families will also give the social worker an understanding of the ways in which family members relate to one another, alliances and conflicts that might exist, and how each family member perceives the others – Social workers should apply an ecological perspective that encompasses complex interactions of individual, social, and

transpersonal factors that impact children and their families, leading to the development of appropriate family-centered services and supports. A complete assessment of each family member is helpful to understand the extent and nature of the effect that family structure has had on the family member and its impact on other life areas – The needs of all family members should be assessed in order to disentangle various contributors to their difficulties,

rather than focusing solely on the severity of the child’s behaviors or parents’ current state of mind – Interventions designed to strengthen or correct problems in the parent-child relationship and build a sense of trust and

safety for the child may be necessary in order to stabilize the family and enable children to progress in other areas • Direct observation

–A major source of information for the biopsychosocial-spiritual assessment is the social worker’s direct observation of the client in a variety of environments. Observation of clients can take place during the direct client interview, as well as through observations of the client in his or her environment. During environmental observations, the social worker may choose not to interact with the client, but rather to observe the client’s natural way of interacting with his or her environment (e.g., observing how a child interacts with his or her peers at school). Nonverbal information about the client can be observed in his or her manner of dress and in the body language and facial expressions he or she uses with the social worker and others, including family members, friends, and other professionals. Observations can be made about the client’s executive functions, such as flexibility, problem-solving skills, and frustration tolerance

–Observations of adolescents can take place at school and in peer groups as well as during joint interviews with the adolescent and the adolescent’s caregivers. Observations of the client in the classroom can provide the social worker with information on the client’s interactions with authority figures, as well as his or her ability to handle frustrations or redirection from authority figures. Observing peer interactions provides information about the client’s social development and the quality and type of peers with whom he or she associates. Family dynamics and style of resolving conflicts can be observed during joint interviews with the adolescent’s caregivers

–Observing children at home and at school, both in the classroom and on the playground, can provide the social worker with a wealth of knowledge about the child’s relationships with peers and teachers, the child’s level of impulse control, and his or her emotional, verbal, and cognitive development in relation to that of peers. Observing interactions between the child and the caregiver can give the social worker a sense of the family dynamics, the child’s attachment to the caregiver, and how the child responds to the caregiver’s parenting style

–Observing older adult clients in the home environment can help the social worker gather information on the client’s level of isolation and whether basic needs are being met. Any physical or mobility restrictions can be noted, as well as the older adult’s ability to adapt to any limitations that are present

–When working with families, it is important to observe interactions between each family member and within specific dyads, as well as the interactions of the family as a whole. Through observation the social worker can gather information about the structure and boundaries of the family, the family’s style of addressing and resolving conflicts, and the ways in which family members engage positively with one another. Observing interactions between the identified client in the family (i.e., the family member whom the family identifies as having the problem) and other family members can also provide information about how the family as a whole might be contributing to the family dynamics

• Information from collateral sources –Collateral sources include caregivers, family members, teachers, employers, and friends. Other professionals can be

valuable sources of information as well. Family members will perceive the client’s challenges and strengths differently from the client him- or herself and can provide firsthand information about the client’s behaviors and their impact on the family system. Adolescents and their caregivers often have very different perceptions of the adolescent’s needs and resources. For children, family members or guardians may be the primary source of historical information such as developmental history, school attendance, and medical background. If an older adult client is dependent on others for physical or financial support, the adult children or caregivers of the older adult should be interviewed in order to understand the level of support or distress that these relationships may present for the older adult and to alert the social

worker to any signs of neglect or abuse. Social workers should understand that family members may present information based on their own biases. Care should be taken to evaluate all sources of information and not rely too much on negative views of the client presented by others. Other professionals such as employers and teachers can also be good sources of information. Persons outside of the family system may evaluate the client’s interactions and behaviors based on the norms and values of the systems within which the client interacts (i.e., school or work). This perspective can give the social worker an idea of how the client is functioning in systems outside of the family

• Standardized screening instruments –Although all of the sources of information mentioned thus far provide subjective information about the client,

standardized screening instruments can be used to gain objective information on the client’s functioning. Social workers can choose from a variety of screening tools based on the issues and concerns of the client. Some of these tools are completed by the client and others need to be completed by the social worker or other trained professionals. Although screening tools should not be used in exclusion to diagnose or determine client needs, they can alert the social worker to symptoms or needs that might not otherwise be identified. Numerous screening tools are available that screen for specific symptoms or disorders. Below is a sampling of tools that are exceptionally useful for biopsychosocial-spiritual assessment because they screen generally for needs in one domain, screen for concerns in multiple domains, or examine the relationship between two or more domains – The WHO Quality of Life spiritual, religious, and personal beliefs scale, brief format (WHOQOL-SRPBBREF), is a

34-item screening tool designed to evaluate personal, spiritual, and religious beliefs and religious practices (Skevington et al., 2013)

– The Spiritual Well-Being Scale evaluates both existential and religious ideas about spirituality. It is a 20-item scale, with 10 items that measure religious well-being and 10that measure existential well-being. The tool is not based on any specific religion or spiritual ideology

– Psychological Adjustment to Illness Scale–Self Report (PAIS-SR) is a 46-item tool that measures the quality of psychosocial adjustment to illness in seven categories: healthcare orientation, vocational environment, domestic environment, sexual relationships, extended family relationships, social environment, and psychological distress

– The Achenbach System of Empirically Based Assessment (ASEBA) is a series of assessment tools that can be used to assess clients between the ages of 1.5 and 90. The ASEBA evaluates the client’s competencies, strengths, and adaptive functioning, as well as behavioral, emotional, and social concerns. Scales vary based on the client’s age. For all ages, scales are available that are to be completed by the client through self-report, as well as scales that are to be completed by others who know the client such as parent, teachers, or significant others (ASEBA, n.d.)

– The Strengths and Difficulties Questionnaire (SDQ) is a 25-item standardized screening tool for use with adolescents. The SDQ incorporates