The International Journal of Psychosocial Rehabilitation


Back to Basics:
An Example Application of a Biopsychosocial Assessment



Elizabeth J. Greeno, Ph.D., LCSW-C
Research Assistant Professor
University of Maryland, School of Social Work
525 West Redwood Street
Baltimore, MD 21201
egreeno@ssw.umaryland.edu

    




Citation:
Greeno EJ (2014)  Back to Basics: An Example Application of a Biopsychosocial
 Assessment
.  International Journal of Psychosocial Rehabilitation. Vol 18(2)  





Acknowledgements:
The author would like to acknowledge the support and guidance of Johns Hopkins University,
 Dr. Michelle Tuten, and Dr. Hendree Jones, and the previous work and generosity of Drs. Ann Marie and Louis Pagliaro.




Abstract
A first step in treating women with substance use disorders during pregnancy is the completion of a comprehensive psychosocial assessment, such as the Mega Interactive Model of Substance Use Among Women (MIMSUAW). This study is guided by the MIMSUAW, a biopsychosocial framework (Pagliaro & Pagliaro, 1996, 2000). Findings from the MIMSUAW indicate baseline functioning and can be applied to treatment planning. This study supports the use of structured  psychosocial assessment by social workers.

Key Words: biopsychosocial assessment, assessments, psychosocial characteristics substance use, substance use during pregnancy


Introduction
Psychosocial assessments go beyond questions asked in a typical interview and allow the social worker guidance to describe the demographic, personal characteristics, history, and current biopsychosocial status of individuals seeking treatment (Comfort & Kaltenbach, 1995). These assessments inform all aspects of treatment including eligibility, programming, and planning. Social workers use psychosocial assessments to engage women in treatment and these assessments provide the opportunity to address psychosocial challenges concurrently with addiction treatment. Psychosocial assessments are often based on biopsychosocial theory.

Biopsychosocial Theory
The more severe, chronic, and widespread the presenting problem, the more unlikely that a uni-modal or restrictive approach will be effective (Sperry, 1988; 2001).  To counter such restrictions, the biopsychosocial theory was first introduced in the late 1970’s (Engel, 1977). This model objects to a linear relationship cause-effect model but rather suggests an integrative and systems perspective that accounts for an individual’s intrapersonal functioning and the impact of the outside world (Sperry, 1988; 2001). The biopsychosocial theory asserts that a person can only be understood if all levels of his/her functioning are taken into consideration; these levels being biological, social, and psychological functioning. Biological functioning, also known as physical functioning (Sperry, 1988; 2001) refers to medical and central nervous system functioning.

Psychological refers to the inner self-conscious processes, representation of self, individual goals/needs/wants, and cognitive processes that govern behavior (Sperry, 1988). Social functioning involves the person’s relationship to others including family, friends, authorities, institutions, and the community. Given the range of variables taken into consideration by this theory, it is often employed in social work practice.

Example Application
Women who use substances during pregnancy frequently have a myriad of psychosocial problems and addressing these problems at the start of treatment can impact treatment efficacy. Common psychosocial characteristics for pregnant women with substance use disorders have been well documented in the literature. This study seeks to apply a biopsychosocial assessment, based on the biopsychosocial characteristics found in previous literature, to a drug-using pregnant population. Table 1 represents a review of 18 studies detailing psychosocial characteristics associated with substance use during pregnancy. Main findings of the reviewed literature suggest that the life events most strongly associated with substance use in pregnancy are: emotional, physical, or sexual abuse; older maternal age, increased conflict with family of origin; lack of social support; partner substance abuse;  greater psychiatric severity, including clinically significant depression; early age of drug initiation; chaotic lifestyles and stress; homelessness; family history of maternal and paternal substance abuse;  number of previous children; limited educational attainment and IQ;  lack of employment; and  involvement  in the criminal justice system, exposure to violence, intimate partner violence (see Table 1 for a review of authors).






Management of substance use disorders during pregnancy is directly related to discovery of the problem (Horrigan, Schroeder, & Schaffer, 2000). A psychosocial assessment has the ability to identify ongoing psychosocial challenges and to provide information that would be essential to treatment planning. In efforts to treat all relevant stressors, psychosocial assessments should be tailored to the population.

Role of Social Workers
Social workers are often the initial contact for pregnant women with substance use disorders, either as direct providers of substance abuse treatment or through the myriad of social service agencies with whom the pregnant woman has contact (e.g., Department of Social Services, Women, Infants, and Children, child welfare system, or schools.). As such, social workers are in an optimal position for assessing and intervening for pregnant women with substance use disorders. Social workers can play a number of roles, depending on the context, including broker, clinician, mediator, case manager, teacher, and advocate (Sun, 2004). Given these various roles, it is important for the social worker to understand the myriad of psychosocial challenges affecting pregnant women with substance use.

Conceptual Framework
This descriptive study is guided by the Mega Interactive Model of Substance Use Among Women (MIMSUAW) (Pagliaro & Pagliaro, 1996, 2000), a biopsychosocial framework. The MIMSUAW was developed to help clinical social workers treat and understand the complex multidimensional etiology of substance use disorders among women without enforcing a single theoretical focus (Pagliaro & Pagliaro, 1996, 2000). This model allows for an assessment of the multiple psychosocial challenges affecting this sample. Pagliaro and Pagliaro (1996) theorize that each substance abuser has a unique substance use milieu. The milieu consists of four interactive variable dimensions: woman, societal, substance, and time dimension. Each dimension consists of a subset of interacting variables that are referred to as unit coteries with each unit representing a phenomenon that impacts substance use (Pagliaro & Pagliaro, 1996, 2000). 

Variable Dimensions

Together the woman, societal, substance, and time dimensions represent an aggregate view of psychosocial challenges that are thought to impact a woman’s milieu. Each dimension is comprised of several unit coteries; this study will refer to unit coteries as variables. Each variable represents an essential component to a substance using pregnant woman’s milieu (see Figure 1).



The woman dimension of MIMSUAW is comprised of physical, psychological, and societal variables. The physical variables describe general health status and the unique physiological experience and reaction a woman will have to substances. Psychological variables include components that are influential in shaping a woman’s current outlook of her health, the health of her unborn child, and her potential to receive successful treatment. Social variables consist of elements related to one’s community and relationship with others. Consideration of all the variables associated with the woman dimension primarily assists in differentiating the unique aspects of each woman’s experience (Pagliaro & Pagliaro, 2000).

The societal dimension is comprised of pertinent communal experiences (e.g., social programs) and is seen as having a significant influence on prevention and treatment of substance using women (Pagliaro & Pagliaro, 2000).  Societal variables are often more realistically and effectively addressed at local and national levels versus being experienced or addressed at the individual level (the Woman Dimension addresses these individual experiences). This study does not address variables from the Societal Dimension.

The time dimension of the MIMSUAW refers to the historic context of substance abuse or use and its relation to the other variable dimensions. Variables of the time dimension include the historic period (e.g., 1960s or 1990s), the length of substance use, and the time period of a user’s life (e.g., middle adulthood. This current study does not address variables from the Time Dimension.

The fourth dimension, the substance dimension is comprised of two variables: substance and pattern of use (see Figure 1). The MIMSUAW model provides a pattern of use variable that details the progression of substance addiction and the events surrounding the progression of use.  There are eight defined patterns of use that represent a progressive continuum of substance use.  The eight patterns are: initial use, social use, habitual use, abuse, compulsive use, resumed nonuse, controlled use, and relapsed use. Compulsive use, the fifth pattern of use variable will be assumed for all study participants. Pagliaro and Pagliaro (2000) describe compulsive use as “the women feel a lack of control over the use of the substance of abuse and continue to use it despite expected and predictable harmful effects (e.g., fetal alcohol syndrome)” (p. 23). Using despite known consequences to their health and the health of their unborn child(ren) is appropriately considered compulsive use. 

Purpose of Study
The purpose of this study is to assess the feasibility of the MIMSUAW as an assessment tool for psychosocial characteristics for a pregnant drug using population. This study will answer the following: Based on what has been reported in previous literature, can the MIMSUAW accurately describe the biopsychosocial characteristics of a pregnant substance using sample? Can alcohol and drug use by pregnant women accurately be described by the MIMSUAW?

Method

This study is a secondary data analysis with a sub-sample drawn from a larger behavioral study of contingency management (see Tuten et al., 2009 for details). Study participants received treatment from the Center for Addiction and Pregnancy (CAP), located at Johns Hopkins Bayview Medical Center in Baltimore, Maryland. CAP is a specialized treatment program that provides comprehensive substance abuse and medical treatment to pregnant substance using women (see Jansson et al., 1996; 2002 for a description). Institutional Review Board approval was obtained from the Johns Hopkins University and the University of Maryland, Baltimore. The sample for this study included 111 participants who were part of interviews conducted from April 10, 2000 through April 19, 2001. Biopsychosocial characteristics were assessed through frequency and descriptive statistics through IBM PAWS 20.0.

Operationalization of Measures
The biopsychosocial characteristics that were identified through a review of the literature were operationalized through the variables in the MIMSUAW for the Woman and Substance Use Dimensions. Questions were asked of the participants during an intake interview.

Results
Research Question 1: Based on what had been reported in the literature, can the MIMSUAW accurately describe the biopsychosocial characteristics of a pregnant substance using sample?

The woman dimension physical variables were assessed through six questions (age, health status, ethnicity, and weeks pregnant at intake). These variables garnered demographic information; the sample is 76.6% African American (n = 85), 19.8% Caucasian (n = 22), and Other (2.6, n = 4).  The average participant’s pregnancy gestational age at intake was 16.4 weeks (SD = 6.6, range 4-28). The average age of participants was 30.4 (SD = 5.36, range 18-40).  Over half the sample were age 30 or greater (n = 67, 60.4%). Chronic medical problems interfered in daily activities for 34.2% (n = 38) of sample participants and 19.8% (n = 22) were taking prescribed medications for a physical problem. The average number of days individuals experienced medical problems (out of the past 30) was 4.25 days (SD = 9.18).

The woman dimension psychological variables were assessed through five questions assessing mental health. Results indicate that depression was the most frequent mental health issue experienced both for the past 30 days (n = 49, 44.1%) and for lifetime (n = 68, 61.3%). Anxiety was the second most common indicated mental health issue for the past 30 days (n = 36, 32.4%) and for lifetime (n = 42, 37.8%). Over a third, 37.8% (n = 42) of the sample experienced both depression and anxiety during their lifetime. Lifetime suicide attempts was indicated by 26.1% (n = 29) and 34.2% (n = 38) had been hospitalized for a psychiatric reason at some point in their lifetime. The average number of days (out of the past 30) the sample had experienced psychological or emotional problems was 14 (SD = 13.4). Only 34.2% (n = 38) reported they had not experienced any emotional problems over the past 30 days.

A series of nine questions were used to assess the social dimension. The average educational level completed was 11th grade (SD = 1.8). At the time of the study 10.8% (n = 12) indicated that they were currently homeless and 88.3% (n = 98) of the sample was currently unemployed. Among those who were employed, past 30 day earnings were, on average, $183.63.

The usual employment pattern for the past three years was indicated as unemployment by almost two-thirds of the sample (64.9%, n = 72) with the remainder of the participants indicating a full-time or part-time job (35.1%, n = 39) as their usual pattern. The average length of the last full-time job was 33.5 months (SD = 35.7). The most amount of money received/earned over the past 30 days was from illegal means ($1,207.64, SD = $3,010.49), followed by money received from mate, family, or friends ($925.90, SD = $1,081.58).

Half of the sample (51.4%, n = 57) had experienced physical abuse at some point in their lifetime. Physical abuse over the past 30 days was experienced by 7.2% (n = 8). Emotional abuse was the most frequent type of abuse indicated both for lifetime and past 30 days (65.8% and 22.5%, respectively). Lifetime sexual abuse was experienced by 31.5% (n = 35). A combination of lifetime physical, sexual, and emotional abuse were experienced by 24.3% (n = 27) of the sample.

 The MIMSUAW variable, dysfunctional family was assessed through a series of questions asking about the relationship with family members. One measure of family functioning asked if study participants had ever had significant periods in which they experienced serious problems with other individuals in their lifetime. Responses indicated the most frequent person study participants had difficulties with was their mother (51.4%, n = 57), followed by sexual partners/spouse (45.9%, n = 51), and brothers/sisters (30.6%, n = 34).  The average number of days sample participants experienced conflicts with family (over the past 30) was 3.5 days (SD = 8 days).

The study sample indicated conflict with other individuals (excluding family). The average number of days the respondents had conflicts with other people was 3.9 days (SD = 8.7 days). Sample participants indicated that only 14.4% (n = 16) had periods of significant problems with close friends in their lifetime. However, 16.3% (n = 17) responded this question was not applicable to them, suggesting they did not have any close friends. Similarly, the average number of close friends was 1.35 (SD = 1.79) with 40.5% (n = 45) of the sample participants indicating they did not have any close friends. The majority of respondents spent their free time with family (56.8%, n = 63). Eighteen percent (n = 20) indicated they spent most of their free time alone and 25.2% (n = 28) indicated they spent their time with friends. The majority of respondents were never married (74.8%, n = 83) followed by 17.1% (n = 19) indicating they were divorced or separated, and 8.1% (n = 9) indicating they were married. 

The substance dimension of the MIMSUAW assesses legal status. A majority of the respondents had been charged with some type of offense in their lifetime (85%, n = 94). The average months incarcerated was 6.5 (SD = 15.5 months). The most frequent type of arrest was drug charges (n = 51, 46%), followed by parole/probation violations (n = 33, 30%), assault (n = 33, 30%), shoplifting/vandalism (n = 31, 28%), and contempt of court arrests (n = 27, 24%).  However, only 24.3% of the sample (n = 27) were on probation or parole at the time of the study. The substance dimension assessed money spent towards drugs/alcohol. Study participants spent an average of $2,231.83 (SD = $2,347.91) on drugs and $29.75 (SD = $117.03) on alcohol over the past 30 days. There are significant differences between the amount of money earned (through employment) and the amount of money received (through mate or family) when compared to the amount of money spent on drugs/alcohol.

Tables 2 and 3 detail the substance consumption (amount and type) for this sample. Results indicate this sample of women enrolled in treatment for substance use disorder is primarily a poly-drug using sample (see Table 2).  Excluding caffeine and nicotine, the drug most frequently used was heroin (89.5%, n = 96), followed by cocaine (73%, n = 81), and alcohol (47. %, n = 53). Method of drug use was collected only for heroin and cocaine use. Heroin use by snorting was indicated by 67.6% (n = 75) of users while cocaine use by snorting was indicated by 11.7% (n = 13).




Table 3

 
Type and Amount of Substances Used

Substance*

% of Users in the Past 30 Days

# of Days of  Use Past 30

 

M                    SD

Alcohol**

47.7% (n =53)

5.36

9.9

Alcohol to Intoxication**

20.7% (n = 23)

3.87

9.16

Heroin

89.5% (n = 96)

23.36

11.4

Methadone

12.6% (n = 14)

1.95

6.9

Cocaine

73.0% (n = 81)

10.6

11.4

Cannabis

24.3% (n = 27)

2.12

6.2

Caffeine

87.4% (n = 97)

21.1

4

Nicotine

87.4% (n = 97)

25.93

10.1

More than 1 drug***

83.8% (n = 93)

12.88

11.8

* = Barbiturates, Painkillers, Sedatives, and Hallucinogens are not included in the table due to low use (less than 10 participants reported use)
** = Alcohol has been measured by number of drinks (not quantity in ounces)
*** = Does not include caffeine or nicotine

Discussion
Findings from this study confirmed the psychosocial challenges that have been found in previous studies for a pregnant substance using population. A biopsychosocial assessment, as applied through the MIMSUAW variables supports findings found in previous literature. Findings from this study suggest that questions asked during an intake interview could be applied to the MIMSUAW, a structured psychosocial assessment. Findings highlight the challenges and impairments experienced by pregnant women with substance use disorders across several areas of functioning, especially those of employment, mental health, legal activity as well as family, social, and medical status. The MIMSUAW framework was able to provide essential psychosocial functioning that would be applied to treatment planning and inform social work practice.

This study was the first known attempt to apply the MIMSUAW to a sample of pregnant women enrolled in substance use disorder treatment. Despite that two of the four MIMSUAW dimensions (the Time and Societal dimension) could not be assessed in this study, the MIMSUAW still proved to be a useful conceptual framework for describing this study sample. The variables assessed through the MIMSUAW are arguably among the most concerning problems experienced by this sample (e.g., employment status, medical status, psychological problems, abuse, conflict with family and others). The MIMSUAW included variables that affect treatment. These variables include basic demographics, abuse experience (past and present), psychiatric severity (past and present), substance consumption, legal status, conflict with family/friends, and basic social support; all variables that can be considered essential in understanding psychosocial functioning. A benefit to capturing these variables is that they demonstrate ongoing problematic life functioning and addiction recovery and potential. MIMSUAW variables can be compared during baseline assessment, through treatment (such as predetermined intervals), and after treatment is completed (Pagliaro & Pagliaro, 2000).

There are significant psychosocial variables the literature indicated were psychosocial concerns for a substance using pregnant population that were not explicitly included in the MIMSUAW. These variables include previous children, custody status of these previous children, partner substance use status, quantity of substance intake per substance use episode, and domestic violence. However, psychosocial assessment can be tailored to the population and it is recommended these specific variables be added to the MIMSUAW.

The application of a psychosocial assessment to social work practice provides a basis for sound social work practice. The psychosocial assessment is a starting point for treatment engagement and provides the social worker the first opportunity to let the client tell his/her own story. The MIMSUAW provided comprehensive coverage of a pregnant substance user’s milieu. It can also provide an organizational tool to guide a social worker through initial treatment contact and treatment planning.  The MIMSUAW requires further replication as a psychosocial assessment to ensure the feasibility and comprehensive coverage of other populations.

Conclusion

This study demonstrated that the MIMSUAW is a biopsychosocial conceptual framework that is a useful and practical psychosocial assessment for a substance using pregnant sample. Tailored psychosocial assessments are necessary to adequately identify and treat client challenges. The MIMSUAW provided information that would inform treatment components and planning as well as inform social work practice. The MIMSUAW gathered information that could be used as a starting point for treatment engagement for pregnant women with substance use.

References
Burns, L., Conroy, E., Moore, E., Hutchinson, D., & Haber, P. (2011). Psychosocial  characteristics and obstetric health of women attending a specialist substance user antenatal clinic in a large metropolitan hospital. International Journal of Pediatrics,  Article ID 729237, doi:10.1155/2011/729237

Comfort, M., & Kaltenbach, K.A. (1995). The psychosocial history: An interview for     pregnant and parenting women in substance abuse treatment and research.  Unpublished manuscript.

Davie-Gray, A., Moor, S., Spencer, C., & Woodward, L. (2013). Psychosocial characteristics and  poly-drug use of pregnant women enrolled in methadone maintenance treatment. Neurotoxicology and Teratology, 38 (11), 46-52.

Engel, G. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196 (8), 129-136.

Flynn, H.A., & Chermack, S.T. (2008). Prenatal alcohol use: The role of lifetime problems with alcohol, drugs, depression, and violence. Journal of Studies on Alcohol and Drugs, 69(4), 500-509.

Flynn, H.A., Walton, M.A., Chermack, R., Cunningham, R.M., & Marcus, S. M. (2007). Brief     detection and co-occurrence of violence, depression and alcohol risk in prenatal care settings. Archives of Women's Mental Health, 10 (4), 155-161. DOI 10.1007/s00737-007-0188-6

Haller, D., Knisely, J., Dawson, K., & Schnoll, S. (1993). Perinatal substance abusers: Psychological and social characteristics. The Journal of Nervous and Mental Disease, 181 (8), 509-513

Harrison, P.A., & Sidebottom, A.C. (2009). Alcohol and drug use before and during pregnancy:     An examination of use patterns and predictors of cessation. Maternal and Child Health Journal, 13 (3), 386-394.

Horrigan, T., Schroeder, A., & Schaffer, R. (2000). The triad of substance abuse, violence, and depression are interrelated in pregnancy. Journal of Substance Abuse Treatment, 18 (1), 55-58.

Howell, E., & Chasnoff, I. (1999). Perinatal substance abuse treatment: Findings from focus     groups with clients and providers. Journal of Substance Abuse Treatment,     17 (1-2), 139-148.

Jansson, L., Svikis, D., Lee, J., Paluzzi, P., Rutigliano, P., & Hackerman, F. (1996). Pregnancy and addiction: A comprehensive care model. Journal of Substance Abuse Treatment, 13 (4), 321-329.

Jansson L, Svikis DS, Velez M, Jones HE. (2002). Impact of managed care on treatment for pregnant drug-dependent women and their children.  Journal of Perinatology, 22 (5-6), 312-13.

Kelly, R.H., Zatrick, D.F., & Anders, T.F. (2001). The detection and treatment of  psychiatric     disorders and substance use among pregnant women cared for in obstetrics. The American Journal of Psychiatry, 158 (2), 213-219.

Kissin, W., Svikis, D., Morgan, G., & Haug, N. (2001).  Characterizing pregnant drug-dependent women in treatment and their children. Journal of Substance Abuse Treatment 21 (1), 27-34.

Kissin, W., Svikis, D., Moylan, P., Haug, N., & Stitzer, M. (2004). Identifying pregnant women at risk for early attrition from substance abuse treatment. Journal of Substance Abuse Treatment, 27 (1), 31-38.

Maloney, E., Hutchinson, D., Burns, L., Mattick, R., & Black, E. (2011). Prevalence and     predictors of alcohol use in pregnancy and breastfeeding among Australian women. Birth     Issues in Perinatal Care, 38 (1), 3-9.

Miles, D., Kulstad, J., & Haller, D. (2002). Severity of substance abuse and psychiatric problems among perinatal drug-dependent women. Journal of Psychoactive Drugs, 34 (4), 339-345.

Moylan, P., Jones, H., Haug, N., Kissin, W., & Svikis, D. (2001). Clinical and psychosocial characteristics of substance dependent pregnant women with and  without PTSD. Addictive Behaviors, 26 (3), 469-474. 

Pagliaro, A., & Pagliaro, L. (1996). Substance use among children and adolescents: Its nature, extent, and effects from conception to adulthood. New York: John Wiley & Sons, Inc.

Pagliaro, A., & Pagliaro, L. (2000). Substance use among women: A reference and resource guide.  Philadelphia, PA: Brunner/Mazel.

Sperry, L. (1988). Biopsychosocial therapy: An integrative approach for tailoring treatment. Individual Psychology 44 (2), 225-235.

Sperry, L. (2001). The biological dimension in Biopsychosocial therapy: Theory and clinical applications with couples. The Journal of Individual Psychology, 57 (3), 310-317.

Sun, A. (2004). Principles for practice with substance-abusing pregnant women: A framework based on the five social work intervention roles. Social Work, 49 (3), 383-394.

Tuten, M., Fitzsimons, H., Chisolm, M., Jones, H.E., Heil, S.H., & O'Grady, K.E. (2009). The impact of mood disorders on the delivery and neonatal outcomes of methadone-maintained pregnant patients. American Journal of Drug and Alcohol Abuse, 35 (5), 358-63.

Tuten, M., & Jones, H.E. (2003). A partner’s drug-using status impacts women’s drug treatment outcome. Drug and Alcohol Dependence, 70 (3), 327-330. 

Tuten, M., Jones, H.L., & Svikis, D.S. (2003). Comparing homeless and domiciled pregnant substance dependent women on psychosocial characteristics and treatment outcomes. Drug and Alcohol Dependence, 69 (1), 95-99. 

Velez, M. et al. (2006). Exposure to violence among substance-dependent pregnant women and their children. Journal of Substance Abuse Treatment, 30 (1), 31-38.


 


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