Mental Health Assessments 

Biopsychosocial Assessment

biopsychosocial assessment, psychotherapy assessment, mental health assessment

Biopsychosocial assessments and how to write and conduct 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. It is an evaluation that takes into account the biological, social, and psychological aspects of someone’s life when determining the cause of their problems.

In 1977, Engel created biopsychosocial theory positing that health and illness were born from a combination of biological, psychological, and social factors. Although commonly accepted now, at the time, health was believed to be a strictly medical domain. As far back as Rene Descartes, the mind and body were thought of as distinct entities that operated separately from each other.

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 can also 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.

 

 

What is a biospsychosocial assessment?

Biopsychosocial assessments differ from assessments that look at 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 on 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?


 

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.

 

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 are 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? 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.
 
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.

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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.
Documenting your biopsychosocial findings can be easily accomplished on EHR/practice management software such as TheraPlatform. It includes a library of assessment templates, which can be modified according to your needs. In addition, one can build any template from scratch. Moreover, TheraPlatform offers built-in intake, consent forms, client portal, scheduling, telehealth (free with EMR), and much more. Sign up for a 30-day free trial now.

 

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