Biopsychosocial Assessment

BASIC SID….

Ingram (2012) describes the problem identification process as involving two key tasks: defining “the presenting problem…[and developing a] comprehensive problem list” (p43). The BASIC SID comprehensive problem framework involves assessing the following areas: “behavior, affect, sensation, imagery, cognitive, spiritual, interpersonal, [and medical]” (p43).   Developed by Arnold Lazarus in the 1980’s, this assessment method allows a holistic assessment of clients, without the influence of theoretical conceptualization in the process (Ingram, 2012).

Click here for my post on the BASIC SID..

Resources

 EXAMPLE OF A BIOPSYCHOSOCIAL ASSESSMENT

HERE IS AN ONLINE BLANK FORM

Key Components of a Biopsychosocial Assessment

At my internship, the biopsychosocial assessment occurred during my first meeting with the client over a two hour period.  This document includes the following key components, ensuring all relevant information is addressed adequately.

Demographic Data

This includes the obvious identifying information for the client including name, DOB, identification number, address, & method of payment.  Other information can include: race, sex, marriage status, and employment.

Presenting Problem

What is the client’s stated reason for entering therapy? Obtaining information on the presenting problem includes not only the nature and history of their current complaints, but their goals for therapy.  In other words, what does successful resolution of this issue look like?  Sometimes intake forms include a current symptom checklist .  This can be a point of discussion, to further define the presenting problem.
  1. The Therapist’s interpretation of the problem:

    1. What is the history, nature, extent, and severity of the problem?
    2. What are the client’s personal treatment goals as it pertains to this problem?
    3. What barriers exist to the achievement of these goals?
    4. What are your observations and feelings overall about the presenting problem.
  2. The Client’s Interpretation of the problem:

    1. What does the client say the reason for coming to therapy?  
    2. ASK:  Why were you referred? or What are some things you might need to work on or would like to see get better?
  3. Family’s Interpretation of the problem. 

    1. What does the family say about the client?  If no family is present than just say no collateral obtained.
    2. ASK:  What does SUZY need to work on or what things can improve?
  4. Others to ask:  referral source, caseworker, school, etc…

PSYCHOLOGICAL: Mental Health History…

Biopsychosocial exams also include a psychiatric history section.   What is the client’s past history with psychiatric treatment, (i.e. outpatient, inpatient, medication list)?  Has the client been diagnosed with a mental illness previously?  My internship site also includes a substance abuse history, spiritual assessment here.  Sometimes these forms include a mental status exam section and functional assessment.
  1. Psychiatric History (hx treatments, diagnoses, medications, etc).

    1. Current Mental Health Symptoms:  What symptoms are they currently displaying?  How long have they been occurring?  symptoms should correlate to the diagnostic criteria
    2. Past Diagnoses: (List any diagnosis from previous providers.  If unknown, write “unknown”)
    3. Previous Mental Health Treatment: Any past providers? Who and how long?  What worked and did not work?  Any medications in the past?
  2. Mental Status Exam & Functional Assessment.

    1. Click Here to Read About the MSE
    2. Current level of mental and physical functioning (describe impairments and skills within to justify)
      1. Mental:  Your interpretation of the client and how you feel their symptoms are affecting their life.  I also include justification for diagnosis..  
      2. Physical:  How is their physical health impacting their functioning?  Do they need to follow up with a PCP?
      3. Co-Occurring disabilities, disorders and medical conditions:  Are there two diagnosis occurring at the same time?  Are you ruling out diagnosis?  IS there substance use or medical issues along with mental health?
    3. Click Here to Read About WHODAS-2
  3. Substance Abuse History (sometimes a separate section).

    1. When discussing the client’s substance use history ask the following:
      1. (typical amount/typical frequency/duration/age at first use/Date last use)
      2. (Tobacco/alcohol/marijuana/opioids/Amphetamines/Cocaine/Hallucinogen/Caffeine.
    2. Client Treatment History: the client had any substance use treatment?
    3. Any known family history of use or any know treatment for such?  
  4. Assessment of risk-taking behaviors  

    1. Elopement Potential
      1. CHILD- Have they thought about running away?  Do they have a plan?  How many attempts have they made?
      2. ADULT- Any history of elopement?
    2. Suicidal/homicidal ideations:  Have they had any current or past-
      1. Suicidal ideations– any attempts, plans, ideations
      2. Homicidal ideations– any attempts, plans, thoughts?
      3. Click here to read my suicide assessment post
    3. Self harming ideations– any cutting, burning, scratching etc?
    4. Imminent risk of harm:  Are they at risk currently
    5. Urgent needs (Describe any high risk situations, including suicide risk, personal safety and risk to others):
      1. Mental:  Are they currently putting themselves at risk behaviorally or with their choices?
      2. Physical:  Any urgent physical symptoms that need to be addressed?

SOCIAL: Family History….

The biopsychosocial assessment also includes information pertain to the client’s family background, social history, and culture.   The following information is obtained: family of origin, current family, marital status, educational background, career history.   Finally, while not included on the form for my internship, other resources suggest a review of the client’s legal history as well as any offender/victim issues.  While not included on my internship’s form, other resources I’ve found include information on the client’s developmental history physically and educationally.
  1. Family of Origin & Current Family

  2. Demographic and historical information:

    1. CHILD-
      1.  Who are their parents and what are their ages.  
      2. Any siblings and ages?  What is the relationship with these people.  
      3. Marriages and divorces of parents.  
      4. If in foster care you may also include the dynamics of the foster family as well.  
      5. Rules of the house and the consequences if not followed.
    2. ADULT-
      1. Parent’s names and ages (or death dates).  
      2. Siblings and ages.  
      3. Current relationships with family and how it was like growing up.  
      4. Any husbands, boyfriends children and their ages.  
      5. What their relationships with them are like.
      6. Divorces, separations, deaths and incarceration of parents and significant others (include reasons):  Are there any deaths or incarcerations or divorces that are significant?  
  3. Current Significant Relationships

    1. families, friends, community members
    2. Marital Status & Sexual History
  4. Abuse & Trauma History

    1. Witnessed or Experienced
    2. Physical / Sexual / Emotional
    3. Any Neglect or Abuse…
  5. Natural Supports

    1. (Describe if there is a need for supports)
    2. Who do they go to when they have problems or need help
  1. Career & educational background

  2. Educational history

    1. CHILD–
      1. What grade and school are they in?  
      2. How are their grades?  
      3. What is their behavior like?  I
      4. typically go back 2-3 years to establish patterns.
      5. Did they need IEP, special education?  Is it working?
    2. ADULT–
      1. did they graduate HS?  GED?  
      2. Any college?  
      3. Any IEP or special education while in school?
    3. Literacy Level:  Where is their reading level? 
    4. Need for Assistive Technology
    5. Vocational history:  Employer/Wage/Position/etc…
  3. Living Situation & Finances.

    1. Who lives in the home?
    2. Whom do they live with?
    3. Source of Income.
  4. Military History

  5. Legal Problems

    1. (victim/offender status)
    2. Any current charges pending or waiting?
    3. Legal history and results.
  6. Spiritual Background

  7. Cultural Background

BIOLOGICAL: Medical History…

Since medical issues frequently influence one’s mental health it is also important to obtain the client’s medical history.  Information obtained includes a list of the client’s medical issues, prescribed medications, history of hospitalizations and surgeries, as well as their primary physician’s contact information.
  1. Significant Medical history

    1. Co-occurring disabilities?
    2. Urgent physicial symptoms?
    3. Diagnoses?
    4. Hospitalization? Surgery?
  2. Medication List:

    1. Name
    2. Purpose
    3. Dose
    4. Date of Initial Prescription
    5. Frequency
  3. Current Physican

    1. Primary care physicians contact information:  Name of doctor and contact information
    2. Did you request a release to speak with the primary care physician?  Yes
    3. Did you make contact with the primary care physician after initial assessment?  Yes, the appropriate form was mailed/faxed.
  4. Developmental History

    1. to include developmental age factors, motor development and functioning
    2. Have they been (or did they meet) their developmental milestones on time?  
  5. Hearing Functioning: 

    1. How is their hearing?  
    2. Have they ever been tested?  
    3. You can also assess auditory hallucinations here.
  6. Vision Functioning: 

    1. How is their vision?  
    2. Do they wear corrective lenses?  
    3. When was their last eye exam?
  7. Immunization Record

    1. (for children/adolescents –
    2. Are they up to date with immunizations?
  8. Prenatal exposure to alcohol, tobacco, or other substances

  9.  PERSONAL ASSETS AND LIABILITIES

    1. Strengths as described by the client:  What does the client state are their strengths?
    2. Limitations:  What needs to be worked on?
    3. Individual needs and Client-identified areas for improvement and desired outcomes:  
    4. What does the client stated they want to improve in therapy?  

Diagnosis & Diagnostic Impression

  1. Diagnosis – simply the DSM-5 diagnoses listed

  2. Diagnostic Impression:  

    1. This is where you will list out the criteria the client meets for the diagnosis above.  
    2. You need to make sure that the symptoms reported earlier match the criteria.  
    3. In reading an IDI a clinician should already see how you came up with this diagnosis

INTERPRETIVE SUMMARY AND TREATMENT RECOMMENDATIONS

  1. Treatment needs and recommended interventions for client and family: What do you recommend?  Individual, Family, Psychological eval, CD eval, psychiatric eval etc.  

  2. What are the issues that need to be addressed?  Justify why? Due to the nature of John’s symptoms, cognitive behavioral therapy is recommended

  3. Identification of who needs to be involved in the client’s treatment: Who needs to be involved?

  4. Plan to meet needs: What is the plan to meet the needs?  Frequency of sessions?

  5. Evaluation of progress: Progress will be evaluated at intake, quarterly, and discharge using the WHODAS 2.0 12-item interview-administered version.

 

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