Biopsychosocial: A Vital Component in Diagnosis and Treatment Planning
A comprehensive biopsychosocial is a critical tool in providing an accurate assessment, diagnosis and treatment plan.
Following is a list of what a biopsychosocial should address:
- Name, address, phone
- Length of time at current address
- How many times client moved residence in past 5 years
- Gender
- Height and weight
- Marital status, including length of time in current relationship
- Is client currently sexually active, if yes, safe sex practices?
- Number of pregnancies & number of living children
- Religion
- Level of education
- Place of employment, address & phone
- Time with current employer
- Emergency contact information
- Names, addresses and phone numbers for all treating physicians
- Medications
- Past mental health care, including whether in-patient or out-patient
- Past suicide attempts?
- Current suicidal ideation?
- Depression screening
- Why relationship with prior psychotherapist(s) ended
- Number of emergency room visits in past year, reason and whether or not the visit resulted in in-patient care
- History of sexual, physical, or emotional abuse
- Family of origin information, including names and ages of parents, siblings
- Assessment of quality of relationship with each member in family of origin
- If in current relationship, assessment of quality of that relationship
- How are disagreements with partner handled
- Who makes decisions
- If children or step-children, ages of children and assessment of quality of relationship with each child
- History of substances: alcohol, street drugs, prescribed drugs including age of first use and frequency of current use
- Regarding history of mental health treatment, what did client find most helpful?
- What are client’s treatment goals?
Knowledge about emergency room visits can shed light on suicidal ideation, the possibility of eating disorders, of anxiety disorders, and domestic violence. Many of the questions lead to important information about the client’s stability and ability to form long-term relationships. Information about past trauma and substance abuse is important for treatment planning, and questions about how disagreements are handled with one’s partner will yield information about the possibility of domestic violence. Information gained from a comprehensive biopsychosocial is vital for proper diagnosis, treatment planning and goal setting.
Sometimes, mental health professionals ask new clients to complete these forms at home and bring to the next session. This could put the client at risk for being triggered and having an adverse reaction. So much can be gained from body language and face-to-face contact – this can provide an opportunity to gain a great deal of information!
Information on biopsychosocials as well as the importance of proper diagnosis can be found in our Medical Error Prevention Course.
Sign up for the Medical Errors Course