To the actor: Have you ever wondered why a character you were reading in a script reacted the way that they did to a given situation? Have you ever wondered why one actor may use explosive anger as a tool while another actor playing the same role may use subtle hints of rage? Well, it is for the same reasons that anyone reacts differently in real life to stimuli: history. The history that each person holds is a wealth of learning, experiences, values, morals and so on. This is what psychology studies and is what a psychosocial assessment is all about. It is not typically a tool used by actors, but by clinicians. I have simply found that using the tool can add depth to any characterization.
A Psychosocial Assessment (PSA) is an important tool to anyone in the mental health or social services. The psychosocial assessment is important because it is a cross section of a person at the moment of time in which the assessment takes place. You learn about all types of intimate information including current job status, marital history, and family information (both past and present)… basically any and all information pertinent to the clients existing condition.
Most importantly, the PSA is the foundation upon which all further interaction with the client is built. I hope I am able to provide you with an idea of how one is written. First we need to know pertinent information about the client’s basic info as you can see in the following section. This is mostly a fictional account with elements of a real case study.
Client Identifying Data
This gives you basic information that may influence a person or character. Cultural, racial, age, sexuality, locality and so on. All of these things may be a factor you need to be sensitive to. Example: A 55 yr old will probably respond differently to death than a 17 year old.
Client Assignation: Mr. Nahasapeemapetilon (Mr. N)
Age: 46 yr. old
Current Residence: Springfield, anywhere
Religious Affiliation: Hindu
Marital Status: Widower
Military Background: Veteran
Admission Date: 11/14/3000
Referred by: Springfield Hospital Emergency Room
Date of Assessment Interview: 11/15/3000
Source of Data
It is important that anyone reading this knows how and from whom all information was obtained. This gives them an idea of how well rounded the history is.
The information in this assessment was gained from the client and his existing medical records only, as no contact information for family members was able to be obtained by hospital staff.
In this section, you describe the immediate details of why the person is in your facility seeking help, whether voluntary or involuntary.
Client is admitted for attempting to commit suicide in his home by cutting his wrist repeatedly with a pocketknife. Mr. N was found by his sister during the attempt who called 911 immediately. Mr. N states that he has been consistently grieving for his wife that died 10 yrs. ago. Since that time, Mr. N reports that he has experienced depressive feelings with no periods of non-depressive feelings. Client reports difficulty coping with loss and feelings have intensified since son was injured in the Springfield/Shelbyville War a few years ago. Mr. N states that he consistently worries about his children and is currently experiencing feelings of anhedonia. Client states that there was no suicidal ideation prior to this attempt and that it was “impulsive”, with no planning or thought of the consequences. As a result, the client has been involuntarily committed pending assessment and treatment.
This section gives one insight into family relations. Are they close/ Can they be counted on for support or are does the client see them as stressors?
Client was raised by his grandparents and biological mother who is now 72 and lives back in India when not visiting Mr. N most of the year. Mr. N states that his family once owned dozens of convenience stores before the majority was donated by his grandfather to Springfield University at the turn of the 20th century. He runs the only one left in Springfield. He is very close to his mother and reports the relationship has always been that way, albeit frustrating. Mr. N states it was a supportive family environment despite the absence of his biological father who “took off” when he was a young child. Biological father passed away when Mr. N was in his mid-20’s, but client reports they never had a relationship. Relations with his two sisters and two brothers have been “so-so”, reports Mr. N, but that they have never been too close. The client denies any significant events in youth that may have been traumatic and affecting his mental health currently. According to client there is no previous known history of mental illness or suicide in his family nor is there any history of substance abuse or addiction. Culturally, he is a native from India and feels more comfortable with incense burning on a statue of Ganesh during sessions.
Here is where you discover any past influences that may contribute to his current feelings. Education, medical history, family status is all important here. So is financial status and military trauma or early abuse of any kind.
Mr. N suffered from the polio virus at the age of four and spent several years walking with leg braces. “It wasn’t that [traumatic], I was young”, states Mr. N. After high school, client joined the Quiki Mart national guard and eventually served on bord an aircraft carrier stationed off the shores of Shelbyville during the war as an engineer. Client denies any traumatic war memories. Since then, client has been married 3 times and has a total of 13 children. Client refused to discuss his children any further stating it was “too upsetting” and noting that one son is consistently in and out of jail and refuses “to take responsibility for his family”. Mr. N attended about eight years of college for engineering and business, paid for by the military. The client eventually owned and ran his own Quickie Mart until he was declared disabled by Social Security and retired 5 yrs. ago with SSI as his only source of income. Client states that there has been no prior history of treatment for any mental illness except for some “nerve pills” his doctor gave him prior to his wife’s death.
A basic description of current medical problems, drugs currently taking, current support system and how he feels he is dealing with problems.
Mr. N has a history of heart problems and is currently taking nitroglycerin and aspirin daily. Client has high cholesterol from eating too much of the food products in the Quickie Mart. Mr. N states he is capable of all activities of daily living, though he may go a day without bathing. He reports that he does not have any friends to socialize with despite being strong at talking with people. Mr. N states that he lives “mostly alone”, caring for his mother, and the client feels he is weak in that he tends to isolate himself. The attached eco-map shows few strong relationships for Mr. N. He reports going to Springfield church where he has been a regular attender since he moved to Springfield. Mr. N states that he does not communicate his problems to his children so that they will not worry about him and he has no other outside support to turn to.
This is complicated so it has been broken down into separate categories, although it can all be combined under a title of just Assessment. Here you will put subjective observations, report client conversation and mannerisms. Then it is up to the social worker or counselor to analyze all the data and provide a diagnosis.
The client has poor insight and judgment, as evidenced by his spontaneous suicide attempt and his refusal to talk to his family about his problems. He presented himself with decent grooming and clothing, and was highly conversational. Mr. N admits to having inadequate stress coping skills which has led to his extended period of grieving over the loss of his wife and his inability to even discuss his children, whom he worries about. Despite his high intellectual function and his strength in conversing, Mr. N has not used these strengths to aid him as of this time for fear of alienating others with his problems.
Mr. N has a distinct lack of interpersonal assets. He has not worked in over 5 years and states that he has no friends to speak of. He still receives income from the quickie mart he owns, but has very little interaction with the employees. Despite his regular attendance at the local Baptist church, Mr. N makes no mention of his church or spirituality playing a large role in his life. He much prefers his solitary Hindu rituals; he attends the church for appearances only. There are no other known interpersonal assets.
Mr. N comes from a large family with four siblings and 13 children of his own but does not make effective use of this family unit. A major stressor is the inadequate communication skills between family members. The client’s mother cannot be counted as strong among these assets due to the fact Mr. N must care for her in her advanced years. In fact, Mr. N made several references to “living alone” despite the presence of his mother in his home. There is a lack of information regarding his children but Mr. N states he finds the topic “upsetting” and so they can be counted among the deficits. It is known that his sister was at his house when he attempted suicide; however there is not enough information to make a determination on how effective the sibling bond is.
The family may be old and well known among Springfield residents, but there is not enough information at this time to make any assumptions regarding the family and it’s interaction with social networks or environment.
You do not have to analyze based on the systems perspective or any particular theoretical perspective, but an analysis must be done from a point of view the interviewer deems as most suited for the client.
The client has a weak ecological system, preferring to maintain status quo through lack of communication. As a result, Mr. N has effectively isolated himself from any social support and ignores the asset of family support he could have by simply refusing to reach out to them about his problems and the family seems content with his lack of communication. His statements lead the interviewer to believe he does not access support from his church, which makes his relationship with his spiritual system conflicted, at best. Despite the strong bond between Mr. N and his mother, the relationship grows more one-sided as he cares for her in her decline into old age which client does not recognize. Worrying about his children is another stressor that has changed what was homeostasis into a decline. Inpatient treatment may be an effective new addition to Mr. N’s system that could serve to strengthen his connections to the other parts of his system. This is necessary if Mr. N is going to repair the functional imbalance that has developed from his lack of interaction with his support systems.
In effect, the lack of strength among his individual subsystems is compounded by the lack of environmental assets to rely on. To then add a dearth of support from the family unit due to inadequate communication and the system does not equate to a functional whole. It is these circumstances which has perpetuated the major depressive disorder over the last 13 years.
Learn how to diagnose using the Diagnostic and Statistical Manual.
• AXIS 1: Major Depressive Disorder
• AXIS 2: None
• AXIS 3: Hypertension, History of heart problems.
• AXIS 4: Inadequate social support, Cares for elderly mother.
• AXIS 5: 35 GAF score.
As identified by the interviewer and the patient themselves.
The two major problems of Mr. N, as identified by the interviewer are:
1. His lack of internal resources to deal with the grief the loss of his wife inspired compounded by the worries nagging the client about his children. Treatment for Mr. N needs to address the lack of coping skills and to change negative cognition.
2. Mr. N has an inadequate social environment which makes for systems dysfunction. Treatment needs to address this by confronting and strengthening the remaining subsystems.
Try to make this decision as carefully as possible and reinforce by supportive peer review journals.
According to a study by Bonano and Lilienfeld (2008), grief therapy is only effective as therapy when the client really needs it, such as clients with complicated grief like Mr. N. Using the strengths perspective, treatment plans include cognitive behavioral therapy consisting of exposure therapy (ET) followed by cognitive restructuring (CR). As outlined by Boelen, et. al, (2007) this series of treatments was significantly more effective in treating complicated grief than supportive counseling. This would also take advantage of the intellectual strength of the client and focus internal resources on developing coping skills and self-regulation skills which are currently lacking. Next, focusing on social systems theory, family sessions will be held to impact systems functioning and improve communication.
Based on the notion that avoiding reminders of the loss is reinforcing in maintenance of complicated grief, ET is the idea that it is important for Mr. N to gradually confront these reminders and the implications of the loss over a four session treatment. First session asks for the client to tell the story of his loss so the therapist can identify particularly distressing aspects to confront. It continues to identify internal and external places that the client tends to avoid and places them on a list in hierarchical order. The next three sessions take that list and gradually confronts them to reduce the emotional impact they have.
Following ET, CR is based on the Boelen, et. al (2007) treatment system. The four session model begins with an introductory session that presents principles that identify and challenge negative emotions and change cognition. Sessions two and three focus on challenging the negative cognitions. The final session will focus specifically on affecting cognitions that are central to the client’s problems and imparting coping skills to help maintain progress.
The final phase of treatment for Mr. N is a series of family sessions aimed at strengthening the family unit and increasing its regulating effect on his system. According to Goelder (1985), the primary assumption in this is that the loss of a loved one brings about a significant destabilization of the social environment. How well the system responds to the reorganization of the social environment is a major factor in determining if grief will be normal or not. For married couples, in the event that the majority of the client’s esteem and needs were met by the spouse, this means there will be a shortage of emotional, cognitive and physical resources leaving a gap. Other relationships must adapt or new relationships created in order to fill the gap left by the loss and leave the client at the same level as before the loss. This method targets the remaining subsystems to strengthen them and replace the lost resources.
The first session has the client discuss family ties with the therapist to identify existing family and social ties and evaluates them in order of perceived importance to client. Once a hierarchical list is made, following sessions can be held between client and other subsystems identified by the list. This will allow Mr. N to open lines of communication with his family and bring them into the loop. Once the needs of the relationship have been identified in session, an attempt can be made to increase efficacy of the relationship to meet the newly identified needs. To this end, establishing a schedule of communication and interaction is crucial. It may be necessary to hold multiple sessions with any given subsystem for maximum effect.
Course of Treatment
Describe the treatment timeline and the potential drawbacks to each so the client is fully prepared to make an informed decision.
Under ideal circumstances, this course of treatment will take several weeks. A minimum of three weeks will be spent as an inpatient in order to complete the CBT portion of the treatment. If kept to a strict schedule, all eight sessions (ET+CR) can be held in that three week period. This will allow the patient to confront negative cognition and learn coping skills prior to returning home. Assuming that self-regulation is achieved, then at the end of three weeks the client may return home and pursue the second half of treatment in an outpatient program. The outpatient schedule allows for flexibility in scheduling sessions with various subsystems in order to account for varying schedules of availability of those people.
The second half of treatment may continue for several weeks, possibly a few months depending on progress and subsystem availability for sessions. Family sessions can be ended and treatment completed when the client feels that his system has achieved homeostasis again and he has the confidence to pursue further relationships on an interpersonal basis, outside of treatment.
Possible concerns regarding treatment include the possibility Mr. N takes the treatment with less seriousness than it needs and fails to achieve self-regulation or complete initial CBT regimen. Another is the concern that family members may refuse to be active in Mr. N’s treatment. Failure of family to attend the second phase of treatment may do harm to the client’s perception of their relationship creating a greater system imbalance. In addition, there is the risk that subsystems in attendance for the second half of treatment may either resent intrusion into “family business” or the implications that their relationship is not adequate. This, too, could lead to greater disharmony. Much of this relies on the ability of the therapist to import the reason and importance of the family sessions to the subsystems prior to and during the sessions.
Once completed, this treatment should ideally complete the goals as stated by the client. Mr. N stated he hoped to “learn how to not worry all the time” (about his children) and to “never want to kill (him) self again” as his goals for. The interviewer feels these goals are consistent with the goals of the treatment, which are to increase coping skills, reduce negative cognition and improve communication between system components to strengthen the overall system function.
END OF PSA
I hope that it is now apparent how important a tool the PSA can be for so many different occupations. Clinicians, social services, acting… I’d be willing to bet it is an invaluable tool for many writers to enhance characterization in their works as well. The PSA gives you so much insight into the present by using past information to give you an idea of how long situations may have been going on and what baseline behavior might actually be for a person. It can explain reasons for current behaviors and be an indicator for potential behaviors.
I hope you have found this guide to be helpful, no matter what your profession is.
Thanks to the SIMPSONS. I used some names and places from that wonderful show in this example.
Boelen, P.A., de Keijser, J., van den Hout, M. A. & van den Bout, J. (2007) Treatment of complicated grief: A comparison between cognitive-behavioral therapy and supportive counseling. Journal of Consulting and Clinical Psychology, Vol 75(2). pp. 277-284.
Bonano, G. A. and Lilienfeld, S. O. (2008) Let’s be realistic: When grief counseling is effective and when it is not. Professional Psychology: Research and Practice, Vol 39(3). pp. 377-378
Goalder, J. (1985) Morbid grief reaction: A social systems perspective. Professional Psychology: Research and Practice, Vol 16(6). pp. 833-842