Fall 2026 SOWK 486w Week 08 - Social Histories in the Context of Biopsychosocial Assessment

Fall 2026 SOWK 486w Week 08 - Social Histories in the Context of Biopsychosocial Assessment

Weeks eight and nine focus on how social workers conduct assessments. Before we can build relationships with our clients and find ways to support them, we must first understand the real problem. Week eight is asynchronous, with no in-person class. We will be examining our assessment process through chapters eight and nine of Hepworth et al. (2023). In the forums, you will discuss the chapters, reflect on implicit bias using the IMPLICIT model, explore screening tools such as the PHQ-9 and GAD-7, and test how observant you are with a short video. This week your teach back group should be working on their video (it is due Monday 10/19/26 at 5 PM), which you will share in the Week 09 forums. My lecture video walks through what goes into a social history as part of a biopsychosocial assessment, and how documentation works in substance use disorder treatment.

The agenda for my lecture video includes:

• Week Eight Content
• Social Histories in the Context of Biopsychosocial Assessment
• Substance Use Disorder Documentation

Learning objectives this week include:

• Identify ethical and professional considerations when using diagnostic tools and clinical terminology as BSW-level practitioners.
• Apply strengths-based and person-in-environment frameworks to assessment practices.
• Evaluate common screening tools for their relevance and utility in social work practice.
• Reflect on how implicit bias and attention shape what we notice during an assessment.
• Identify the core components and structure of a biopsychosocial assessment form, and explain how to gather and organize information across its domains.
• Describe the documentation used in substance use disorder treatment, from screening and intake to discharge, and how the ASAM criteria guide it.

Plan for Week Eight

Agenda

• Week Eight Content
• Social Histories in the Context of Biopsychosocial Assessment
• Substance Use Disorder Documentation

Learning Objectives

• Identify the core components and structure of a biopsychosocial assessment form.
• Explain how to gather and organize information across psychiatric, medical, social, developmental, and cultural domains.
• Describe the documentation used in substance use disorder treatment, from screening and intake to discharge, and how the ASAM criteria guide it.

Week Eight Content

Watch this lecture video

Make 3 Replies Across any of the 4 Forums

• Exploring and Reflection on our Implicit Bias
• Chapter Eight and Nine Content Discussion
• Screening Tools and Assessment Instruments
• How Observant Are You?

Week 09: Teach Back Activities

Examples of the Screeners - GAIN-SS

GAIN-SS - Internalizing, externalizing, and substance abuse.

Connection with screening tools forum and substance use. History using.

SUD Documentation (1 of 2): From Screening to Discharge

In substance use disorder (SUD) treatment, documentation follows a person from the first contact to the end of services. In Washington, behavioral health agencies have required content for each person’s individual service record (WAC 246-341-0640).

• Screening: a brief tool that shows whether a full assessment is needed (e.g., the GAIN-SS from this week’s forum)
• Intake: identifying information, informed consent to treatment, and the counselor disclosure
• Assessment: a strengths-based psychosocial assessment covering presenting issues, risk of harm, a diagnostic statement, treatment recommendations, and an ASAM placement decision
• Treatment plan: the individual service plan, with measurable goals and interventions, mutually agreed on and updated as needed
• Progress notes: progress and group notes documenting the services provided
• Clinical reports: reports to courts, probation, or other providers, which need the client’s written consent under 42 CFR Part 2 (Week 05)
• Discharge summary: completed within seven working days, with the discharge date, continuing care plan, and current medications

[Content Note] ✅ SUD (q)

(Individual service record content, 2023; Hepworth et al., 2023)

SUD Documentation (2 of 2): ASAM Dimensions in the Assessment

The American Society of Addiction Medicine (ASAM) criteria are guidelines for the placement, continued stay, transfer, or discharge of clients with addiction and co-occurring conditions. In Washington, the record has to show that ASAM criteria guided each of those decisions.

The six dimensions organize the assessment and the treatment plan:

1. Acute intoxication and/or withdrawal potential
2. Biomedical conditions and complications
3. Emotional, behavioral, or cognitive conditions and complications
4. Readiness to change
5. Relapse, continued use, or continued problem potential
6. Recovery/living environment

On a biopsychosocial form, the substance use section often includes age at first use, primary drugs used, patterns of use, past treatment, and family history of substance use problems.

Anything in the client’s record can be subpoenaed. Write the assessment as if a judge and jury could read it.

[Content Note] ✅ SUD (q)

(Hepworth et al., 2023; Individual service record content, 2023)

Biopsychosocial Assessment: What Goes On The Form

The format and structure of a biopsychosocial assessment varies greatly in how it is organized, understood, and considered. Forms are sometimes open headings and other times used with checkboxes or drop down menus. The following is the content that was identified by Hepworth et al. (2023):

• Identifying information (e.g., name, age, referral source)
• Presenting Problem (i.e., the presenting problem, symptoms, history of problem)
• The past psychiatric and medical history of the client and the client’s family (e.g., injuries, operations, medical conditions, medication, ongoing medical treatment)
• The client’s social history (e.g., overview of client’s childhood, family structure, living situation, employment and employment history, educational history, hobbies, daily routine, religious or spiritual preferences, friends, past trauma, substance use)
• A mental status exam and DSM-5 diagnosis
• A formulation (e.g., a statement that summarizes and synthesizes the most important aspects of the case to create a story of the client and their past and presenting problems)

Simple Assessment Example

I’m going to go through and talk about the questions and things I would look for during an assessment and I wanted to show you a simple version. Your assessment can look just like this, just a simple document.

Show: Student Social History form I created and used at the Pasco School District

2018-01-17, Social History or Social Worker Report.pages

Areas of Assessment in a Biopsychosocial Evaluation (1 of 5) General Areas

We generally assess the following areas:

• Presenting Problem
• Domains with Potential Needs
• Impressions and Recommendations

Areas of Assessment in a Biopsychosocial Evaluation (2 of 5) Strengths in Managing Presenting Problem

We assess for strengths throughout the interview, and it can help us understand their presenting needs as well as each domain that we assess for.

Some questions we might ask include:

• How have you been coping with your presenting problem?
• What resources or supports have you been using?
• What qualities do you have that have enabled you to keep going in the face of such difficulty and stress?

(Hepworth et al., 2023)

Areas of Assessment in a Biopsychosocial Evaluation (3 of 5) Central Questions to Assess the Presenting Problem

In finding out what the presenting problem is, there are some central questions that guide the focus of the interview to understand the presenting problem.

• How severe is the problem?
• What meaning does the client ascribe to the problem?
• Where does the problem occur?
• When does the problem occur?
• How often does the problem occur?
• How long has the problem existed?

We don’t ask these questions, but they guide our assessment.

(Hepworth et al., 2023)

Areas of Assessment in a Biopsychosocial Evaluation (4 of 5) Domains with Potential Needs

The following are some of what I think about as common areas we might evaluate for in a a assessment. The content that we might draw from each one is different and dependent on setting.

• Psychiatric history (e.g., Px Dx, Family Dx/problems)
• Medical History (e.g., injuries, operations, medical conditions, medication, ongoing medical treatment)
• Substance abuse
• Trauma, safety, and risk
• Family (relationship, connections)
• Social supports (quantity, connection, group involvement)
• Developmental history
• Education and employment history
• Strengths and resources
• Cultural and spiritual

Areas of Assessment in a Biopsychosocial Evaluation (5 of 5) Impressions and Recommendations

Finally, assessments have a place for us to share our impressions and recommendations.

These might include:

• At a MSW level -> A mental status exam and DSM-5 diagnosis
• Summary and formulation
• Recommendations