Biopsychosocial assessment

Biopsychosocial assessments are commonplace tools and practices for many practitioners, although not everybody agrees with the model. The biopsychosocial assessment is a logical offshoot of psychiatrist George Engel’s biopsychosocial theory.

Engel created the biopsychosocial model in 1977 to acknowledge the biological, social, and psychological elements that contribute to a person’s overall health.

It was a departure from the predominant theories of the time, which held that health and illness were primarily due to biological factors. As far back as Rene Descartes, the mind and body were thought of as distinct entities that operated separately from each other.

In the 21st century, however, it is hard to imagine evaluating mental and physical health conditions without considering psychological and social factors. Here is what therapists need to know about biopsychosocial assessment.

Summary

• The biopsychosocial model recognizes that biological, psychological, and social factors all contribute to a client’s mental health, making it a comprehensive approach to assessment and treatment planning.

• Practitioners don’t need to ask every question in every domain—assessments should be personalized based on the client’s presenting issues to ensure relevance and effectiveness.

• Summarizing findings with both objective data and clinical impressions—including diagnosis and treatment goals—helps guide care and supports continuity. Download my free counseling treatment plan template.

• EHR systems like TheraPlatform simplify biopsychosocial assessments with customizable templates, integrated intake forms, and built-in telehealth, improving workflow efficiency for therapists.

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Engel’s theory was revolutionary and initiated an effort for medical and mental health professionals to look at people more holistically.

The biopsychosocial theory is an acknowledgment that we don’t live in a vacuum and that biological, social, and psychological influences interact in determining human behavior and emotions.

For example, episodes of depression may not be driven by purely psychological factors. They may be caused by medical problems or environmental stressors. Currently, the biopsychosocial model has applications in understanding a wide range of medical and psychological issues, as well as overall human development.

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What is a biopsychosocial assessment?

Biopsychosocial assessments differ from assessments that examine primarily one area, such as a psychological or medical evaluation. A biopsychosocial assessment is done at the beginning of mental health treatment, usually as part of the intake phase. It is a series of questions that clients are asked to answer honestly.

Because of its comprehensive nature, it may take longer to conduct than a more traditional therapy intake assessment. While a biopsychosocial assessment can be performed as part of a more general evaluation, it is usually done to help address a specific presenting problem.

A biopsychosocial assessment is often done in the context of psychotherapy, but can also be done by medical and social work professionals who are not therapists.

What is included in a biopsychosocial assessment?

As the name suggests, questions about the assessment are related to the three domains, namely biology, psychology, and sociocultural influences.

Biology

Biological factors involve genetics, physiology, chemistry, and neurology. Questions will address diet, sleep habits, and family history.

An example of a few possible biology questions is as follows:

• Do you take any prescription medication or supplements? If yes, what are they?
• Do you have any medical problems that you believe significantly impact your life?
• Is there a family history of significant medical problems or disease? If yes, what are they?
• Have you had any surgeries or hospitalizations in the past?
• Describe your current and past use of alcohol, drugs, and tobacco.

Psychology

Psychological factors involve a person’s personality, thoughts, and ensuing emotions and behavior. Questions address current cognitive functioning, coping skills, and mood.

An example of a few possible psychology questions follows:

• How would you describe your mood? Do you have a history of suicidal thoughts or acts of self-harm?
• Do you have a family history of psychiatric illness?
• Name three of your strengths and three of your weaknesses.
• How would you describe your overall mental state?
• Have you ever been in therapy or taken medication for mental health?
• Have you experienced any traumatic events in your life?

Social

Social factors involve any interpersonal or environmental aspect that affects a person’s thoughts, feelings, and behavior. Questions will address the quality of family relationships, financial stability, and educational background.

An example of a few possible social questions include the following:

• Do you have close relationships with family members? Do you find them a source of emotional support?
• Do you currently have a job? Does it provide you with personal satisfaction and financial stability?
• What is happening in your life right now that increases your stress level? What about in the past?
• Do you have close friends or a support system you can rely on?
• What kind of work do you currently do? How much stress does your job cause?
• How is your current financial situation?
• Have you had any legal issues, including being arrested or sentenced for a crime?

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Tips for conducting a biopsychosocial assessment

• Realize biopsychosocial assessments do not always yield relevant information in all three areas. For example, you may find that job stress (i.e., a social factor) is associated with a client’s anxiety but cannot find any biological reasons for their anxious feelings. That is okay. Don’t make up or exaggerate reasons to say that a problem is influenced by all three domains.
• You don’t have to ask all the questions in the assessment. Some questions can be asked in written form, or through an intake packet. To save time, a client may be able to fill out the more general questions at home or in the waiting room before your initial meeting. The advantage of a face-to-face interview is that you can gauge non-verbal cues and ask follow-up questions. As a result, you may want to save questions that appear more relevant to the presenting problem for verbal questioning.
• All of the data may not be relevant to a client’s presenting problem. It is important to sift through it and choose the best information that will help you address their current difficulties.
• Further, while it may be tempting (and easier) to create the same assessment to give to every client, it may be ill-advised to ask everyone the same questions. For example, if a client is seeking therapy due to the death of a loved one, you may not be overly concerned with their past medication history. When possible, ask specific questions tailored to the presenting problem.

Use the following suggestions to optimize results, and reduce time and effort in completing a biopsychosocial assessment:

Not all domains are equal

Although a biopsychosocial assessment examines the interplay between three domains, that does not mean that all three play the same role in the client’s health.

For instance, an individual may have several serious issues in psychological functioning, but be in excellent physical health. In that case, the psychological domain will be emphasized in the summary and recommendations, while not much may be mentioned about the physical domain. This is perfectly acceptable. Every person is different, and the clinician must focus on the most relevant aspects of a person’s functioning.

Follow-up and clarifying the biopsychosocial assessment

A lot of information is presented in a biopsychosocial assessment. Some of it is self-explanatory, but much of it may be confusing or need clarification. This is especially true if the paperwork was filled out before the intake session. The clinician is encouraged to follow up on relevant areas and seek clarification to establish a more accurate and complete picture.

Use outcome measures

It is always important to use standardized tools when possible to reinforce clinical impressions. Quick screening measures, such as the PHQ-9 and GAD-7, can provide objective results that support clinical findings. What’s more, modern EHRs allow clients and therapists to administer, score, and track these measures with minimal effort.

Objective facts vs. subjective impressions when using an biopsychosocial assessment

It is critical to distinguish between objective and subjective information in the biopsychosocial assessment. The client will provide objective information when answering questions related to the three domains, but the clinician’s impressions (e.g., diagnosis, client affect) are considered subjective. Therapists must take pains not to present subjective thoughts as facts. Subjective information should primarily be presented in the summary section and identified as such.

Synthesize with the 4 Ps

Organize the narrative summary using the “4 Ps”: predisposing, precipitating, perpetuating, and protective. Synthesizing all the information in a biopsychosocial assessment can be difficult, and using the 4 Ps rubric can help you weave it all together.

Biopsychosocial assessment template

Here is a sample template of what to include in a biopsychosocial assessment report:

Demographic information

Name, date of birth, gender, etc.

Presenting problem

What is bringing you into treatment? What current symptoms are you experiencing? The therapist may also note the client’s appearance and functioning during the assessment.

Biological components

• Medical history
• Allergies
• Current medications (including supplements)
• Substance use history
• Physical health and any current problems
• Family medical history

Psychological components

• Mental health history, such as diagnoses and treatments
• Personality traits
• Current emotional state
• Cognitive Functioning (e.g., attention, memory)
• Coping mechanisms and examples of resilience
• Trauma history

Social components

• Family system and dynamics
• Non-familial relationships
• Education and employment history
• Cultural and spiritual background
• Legal and financial status
• Community support and available resources

Narrative summary

The narrative summary is an organized overview of the information presented as interpreted by the therapist. The clinician highlights the most relevant aspects of the assessment as they relate to current and past functioning. This includes the therapist’s clinical impressions, diagnosis, and client strengths and weaknesses.

Recommendations

Most biopsychosocial assessments conclude with further suggestions for treatment, including therapy and medication management. Based on the therapist’s impressions, goals for treatment are outlined and provide a stepping stone to formulation of the treatment plan.

Is biopsychosocial assessment necessary?

Many therapists already include certain questions about biological and social factors in their intake questioning. Regrettably, clients do not usually get treated with comparable emphasis. In traditional therapy assessments, prioritizing psychological factors is the norm. While that remains important, it does not take into account the impact that other factors may have on a person’s mental state.

What has become increasingly clear over the past 50 years is that the mind, body, and environment do not act independently. Human beings are affected by an interaction of hundreds of factors and it is virtually impossible to determine the exact influence of all those moving parts. It is only when we examine biological, social, and psychological facets equally that we can appreciate their influences on human behavior.

A biopsychosocial assessment recognizes the crucial role each domain plays in an individual’s difficulties. An analysis that does not acknowledge their importance is both inaccurate and incomplete. Thus, biopsychosocial assessment is necessary because it explicitly examines the holistic reality of human nature.

Documenting your biopsychosocial assessment findings

After conducting the assessment, most practitioners create a short summary of their findings identifying the client’s primary issue and its level of urgency. Secondary factors should be detailed as well. In addition to what you uncover during the assessment, also provide your description of the client’s appearance and actions including any body language that might indicate anxiety and depression or how they’re handling and presenting the problem.

Additionally, include your diagnosis weighed with any previous diagnosis. Finally, write down short- and long-term goals recommending the best treatment options and recommendations for resources and services.

Improving mental health assessment notes with EHR software

EHR software and practice management tools, such as TheraPlatform, offer numerous advantages in creating accurate, efficient, and organized notes.

Top 7 benefits of using EHR for notes management

Manually writing and storing notes can be cumbersome for many therapists. That process can be further exacerbated by simple document requests that include locating, faxing or scanning documents.

Features like customizable templates, secure storage, easy sharing, duplication, electronic signatures, and efax integration, streamline the note process, optimizing therapy documentation and workflows.

• Consistent notes with template library: EHRs equipped with a library of note templates enable therapists to create standardized and concise notes quickly. This feature ensures consistency across notes, making it easier to review client progress. Additionally, EHRs provide centralized storage and management of notes, enhancing accessibility and organization.

Screenshot of TheraPlatform's notes library.

• Customizable notes: Not all EHRs offer customizable note templates tailored to therapists' unique needs. However, with a robust and user-friendly note template builder, therapists can customize note templates to align with their preferred note-taking style. This flexibility allows for efficient data entry, whether therapists prefer separating sections or using a single note field or checkboxes for mental status or techniques.

Screenshot of TheraPlatform's notes builder. Use existing templates or create your own with new fields like pick lists, checkboxes, and buttons.

• HIPAA-compliant note storage: EHRs prioritize data security by implementing bank-level encryption to safeguard notes and other client information. TheraPlatform, for instance, ensures HIPAA compliance by offering signed, legally-binding Business Associate Agreements to protect Protected Health Information (PHI) between compliant entities.
• Seamless note sharing with clients: Clients may request access to their notes to better understand their treatment or keep them for record-keeping purposes. Using an EHR, therapists can securely share notes with clients, saving time compared to paper-based practices. TheraPlatform, a HIPAA-compliant EHR for therapists, facilitates secure note sharing with clients.

Screenshot of the popular DAP note template created with TheraPlatform. Built-in templates allow for consistent and standardized note-taking.

• Duplicate notes: In cases where the data remains the same across multiple sessions, duplicating notes can save time. This feature is particularly useful when clients exhibit repetitive behaviors or show minimal progress, allowing therapists to refer back to previous notes for accurate documentation.
• Client signatures made easy: EHRs streamline the process of requesting client signatures. TheraPlatform's Pro and Pro Plus plans enable therapists to request electronic signatures directly on notes. Clients can conveniently download and print the documents requiring their signatures.
• Easier faxing: TheraPlatform offers efax integration as an add-on feature, eliminating the need for toggling between multiple services. This integrated solution allows therapists to send and receive documents, including notes, via fax directly from TheraPlatform. Additionally, received faxes can be easily filed under the respective client's charts.

Additional tools and outcome measures to help with data collection and progress monitoring

Therapists can also take advantage of EHRs (such as TheraPlatform)  that offer integrations with Wiley treatment planners to ensure consistent data collection on progress from session to session. The best part about partnering with a modern EHR is the time you save on formulating the actual notes and scoring. 

What is Wiley Treatment Planner? 

Screenshot of TheraPlatform’s Wiley Treatment Planner integration. Wiley offers thousands of prewritten, evidence-based treatment goals, objectives, and interventions for mental health therapists in private practice.

Wiley Treatment Planner is a widely used clinical resource designed to help mental health professionals and other therapists efficiently create treatment plans for their clients. In addition to treatment plans, the company also provides prewritten therapy notes for some diagnostic codes. It is part of the "PracticePlanners" series published by Wiley.

Features of Wiley Treatment Planner include:

• Prewritten, evidence-based treatment goals, objectives, and interventions
• Treatment planners tailored to specific populations and problems, including adults, children, adolescents, couples, families, addictions, and more
• Alignment with the diagnostic criteria from the DSM-5 and ICD-10
• Prewritten therapy notes 

Is there an online version of Wiley Treatment Planner and how can I get the Wiley Treatment Planner?

Wiley Treatment Planner company partnered with a select number of EHRs for mental health providers to make treatment planners available online. TheraPlatform’s EHR offers the Wiley Treatment Planner as an add-on for both assessment and treatment plans and therapy notes, such as notes. You can edit prewritten notes and add your own with any therapy template on TheraPlatform.

Save time with automatically scored outcome measures

Mental health therapists can use outcome measures to document progress and track key clinical indicators to help providers make data-driven decisions and improve client communication and outcomes. Additionally, outcome measures help therapists adhere to compliance requirements and provide necessary documentation to support reimbursement.

While outcome measures clearly provide benefits to both clients and therapists, they can be time-consuming, especially if clinicians score responses manually. However, many aspects of outcome measures can be automated through an EHR like TheraPlatform:

• Sending measurements: Common assessments such as the PHQ-9 or GAD-7 can be automatically sent to clients and stored in their records, or they can be scheduled in regular intervals.
• Auto-scoring: TheraPlatform automatically scores and sums totals for common outcome measures.
• Report building and analysis: Results can be analyzed over time, with visual charts showing progress on rates of severity and session-to-session progress.

Screenshot of a scored outcome for the PHQ-4 on TheraPlatform’s EMR

By regularly using these measures, therapists can gain valuable insights, tailor interventions, and improve client outcomes while demonstrating the effectiveness of their care without manual entry.

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• Scheduling
• Flexible notes
• Template library
• Billing & payments

• Insurance claims
• Client portal
• Telehealth
• E-fax

Learn More

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References

Borrell-Carrió, F., Suchman, A. L., & Epstein, R. M. (2004). The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Annals of family medicine, 2(6), 576–582. https://doi.org/10.1370/afm.245

PsychDB. Biopsychosocial model and case formulation. https://www.psychdb.com/teaching/biopsychosocial-case-formulation

TheraPlatform. Counseling treatment plan template. https://www.theraplatform.com/blog/927/counseling-treatment-plan-template