Information Gathering/Assessment

Assessment is an ongoing process when working with clients. However, the initial assessment is important complete in order to have a fuller picture of the client and in order to gauge intervention process. Typically, a biopsychosocial assessment is completed as the written format for this initial assessment.

This document includes:
Identifying Information such as demographics, referral information, and where the information for the assessment was obtained
Presenting Problem
Current Situation
Previous Mental Health Problems & Treatment
Background Information
Results of Mental Status Exam & Diagnosis
Analysis
Recommendations/Intervention Plan

It is important to have information not just regarding the client's mental health, but biological information such as a medical assessment with information from client's self-report as well as from a physician if consent is obtained and documents such as lab results.

Social information included in the biopsychosocial would also include information regarding family and family dynamics such as communication patterns. This information also includes how culture has impacted the individual and other non-relative social supports including organized agencies that impact client. Also, social worker needs to explore the stressors involved in a clients life - financial, societal pressures, legal problems, discrimination. Some of this information can be viewed in a graphic method of gathering data. This can be in the form of a genogram that depicts a family for at least 3 generations (client, parents, grandparents) and can show the relationships and dynamics between family members. Another one is a ecomap which shows how the family functions in society as a system and shows relationships of other systems within their environment. There is also PIE system which concentrates on the person's roles and how they feel they fulfill those roles. Another graphic method is the Self Concept and Motivation Inventory (SCAMIN) which is a long name for a simple approach. The client (usually a younger child) or family utilizes a smile, straight line, or frown to depict how they feel about a person.

Psychological information is obtained from reports from a psychiatrist or psychologist and from structured tests. It also includes a history of symptoms due to mental health. It is important to note that the social worker is looking not only for symptoms but also for strengths such as personal attributes or coping skills that the client already has and can be utilizes in treatment.

All of this information is best obtained not only from the client but from the environment around the client including the family and doctors. Proper consent must be obtained. It is also important to meet with the client in person in order to do the assessment as nonverbal cues may give you a better insight into the client's mannerisms and taboo topics. Observing the client while in the client's home can also provide valuable information as they tend to be more relaxed at home and social worker can pick up information from the home environment and quality of life for client.

While some structured tools are primarily only for doctors or psychiatrists and psychologists to interpret, there are many that Social Workers can also administer for assessment purposes. This can help gather information that the client might not otherwise tell the social worker verbally. A lot of tools are based around quantitative data - or numerical data. This helps the social worker in a couple of ways. The social worker can be sure that they identified the problems or concerns correctly, numerical data allows them to use the information in clinical articles, it can help to track the progress of the client through treatment, the client may tend to trust quantitative data more, and becoming more familiar with tools that utilize quantitative date allows the social worker to use more tools.

Most of the information, however, is obtained and termed qualitative data or verbal/narrative data which is usually more flexible than quantitative data. Ways of gathering this information is through interviewing the client as stated above. While most social workers and therapist don't name their approaches, there are names for various interviews.

Narrative method is a written or verbal form that links events, cognitions, and emotion. There are 3 kinds:
        Process Recording: This is a written report that details first the basic information of the session (demographics, time, etc). It then transcribes the interview/session verbatim and records all nonverbal behavior. The social worker would also include a record of conclusions and a review of reactions of social worker to session. Lastly, there is a section for anticipated goals with client and social worker.
       Case Study: What is most important is that data is obtained from more than one data source. The social worker creates a record of the main ideas of what has been covered in sessions, keep session within a designated time frame in order to aid in memory and accuracy of notes, record of order and framework of events, notes and report of sessions with conclusions and cognitions ASAP after sessions, and always create the notes before discussing with another social worker.
      Self-Characterization: The client creates the report through journals, diaries, logs. It can use the third person such as having the client pretend they are a close friend writing about the client. This is then used to observe how the client thinks about their environment and what positions client think they are obligated to fill

There is also the ethnographic interview which attempts to capture the client's environment, vernacular, idioms, and world views w/o projecting the social worker's environment, vernacular, idioms, or world views onto client. There are, again, 3 types:
     Structured - the questions in this interview are developed beforehand and does not leave room for the interviewer to ask any clarifying questions or for the client to detour from path.
     Semi-structured - questions are developed beforehand but the social worker has flexibility and the interview is allowed to go off path.
    Open-ended - there is no pre-planning; the interview takes natural course.


Sands, R.G. (2001). Clinical social work practice in behavioral mental health: a postmodern approach to practice with adults. Person Education Company, MA.