Treatment FAQ

how to write a treatment plan for a biopschosocial assessment

by Casper Hettinger II Published 3 years ago Updated 2 years ago
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Brief summary: In about three to five sentences, summarize what you've already written in your report. Your summary should include the primary problem your client has and the contributing factors. Describe your client's level of urgency regarding the problem. Mention any secondary issues or concerns your client shared.Nov 24, 2020

What is the biopsychosocial model of treatment?

The biopsychosocial model has been described both as a philosophy of clinical care and a guide for clinical practice [1]. It proposes that suffering, disease, or illness involve a host of factors from biological (tissues, structures, molecules) to environmental (social, psychological).

What questions are asked during a biopsychosocial assessment?

Describe your childhood: Did you experience physical, sexual, or emotional abuse or neglect growing up? If so, please describe: Do you know of any other traumatic events while growing up? If so, please describe: Do any family members have a history of mental illness or a problem with alcohol or drugs?

What is an example of biopsychosocial approach?

BIOPSYCHOSOCIAL APPROACH: People may start smoking for PSYCHOLOGICAL reasons, such as thinking it makes them less stressed or because of personality traits (extroverts are more likely to smoke). People may start smoking due to SOCIAL networks or perceived cultural norms.

What are the 3 domains of the biopsychosocial model?

A key aspect of the biopsychosocial model is the importance it places on the interconnections between the three domains of biological, psychological, and social functioning.

How do you write a biopsychosocial assessment paper?

Brief summary: In about three to five sentences, summarize what you've already written in your report. Your summary should include the primary problem your client has and the contributing factors. Describe your client's level of urgency regarding the problem. Mention any secondary issues or concerns your client shared.

How do you start a biopsychosocial assessment?

First give a brief, 3-5 sentence summary of what you have already written:Identify the primary problem, need, or concern the client is dealing with and contributing factors.Also, describe the sense of urgency the client has with the problem/s.Identify secondary problems, needs, or concerns if these are raised.

What are the 3 main levels of analysis in the biopsychosocial approach?

The biopsychosocial perspective is an integrated approach to psychology that incorporates three different perspectives and types of analysis: biological, psychological, and social-cultural.

What are examples of biopsychosocial factors?

The biopsychosocial modelBiological (e.g. genetics, brain chemistry and brain damage)Social (e.g. life traumas and stresses, early life experiences and family relationships)Psychological (e.g. how we interpret events as signifying something negative about ourselves)

What is biopsychosocial formulation?

The biopsychosocial formulation is an approach to understanding a patient that takes into account biological, psychological, and social perspectives on the patient's current presentation. Such an approach is especially important for patients with complicated presentations.

What are the key fields of a biopsychosocial assessment?

IntroductionBio (physiological pathology)Psycho (thoughts emotions and behaviours such as psychological distress, fear/avoidance beliefs, current coping methods and attribution)Social (socio-economical, socio-environmental, and cultural factors suchs as work issues, family circumstances and benefits/economics)

What are the six biopsychosocial model of development?

The biopsychosocial model reflects the development of illness through the complex interaction of biological factors (genetic, biochemical, etc.), psychological factors (mood, personality, behaviour, etc.) and social factors (cultural, familial, socioeconomic, medical, etc.).

What are the core assumptions of the Biopsychological approach?

Key assumptions of the biological approach: There is a direct correlation between brain activity and cognition. Biochemical imbalances can affect behaviour. Brain physiology can affect behaviour. Behaviour can be inherited (as it is determined by genetic information)

How often do you speak to a client about anxiety?

The client will acquire social skills and engage in social interactions by speaking to three times a week and taking part in extracurricular activities to improve self-esteem. The client will identify triggers for her anxiety and use coping strategies to reduce anxiety.

Does the client have a history of psychiatric hospitalizations?

The client has no history of psychiatric hospitalizations, suicidal/homicidal ideations or self-harm. However, she was exposed to trauma related to domestic violence and sexual abuse at age six, and as a result, she spent a year in foster care.

What is biopsychosocial assessment?

A biopsychosocial assessment helps counselors, social workers and other behavioral health professionals learn about their clients on multiple levels and better understand their subjective viewpoint. As a result, biopsychosocial assessments enable therapists to diagnose and effectively treat their clients.

What is the psychological component of biopsychosocial assessment?

The psychological component of a biopsychosocial assessment aims to paint a picture of a person’s thoughts, feelings, behaviors and overall mental state.

What are the components of biopsychosocial?

The biopsychosocial model includes three components: psychological factors, biological factors and social factors . You’ll want to focus on these aspects as you gather data for your assessment via patient questionnaire and face-to-face interviews. To show you what to cover, here are descriptions of each component: 1. Biological Factors.

What are the social determinants of mental health?

According to a review published in Current Psychiatry Reports, social determinants, such as income level and familial relationships, can significantly impact mental health. For example, according to the review, studies show a correlation between poor mental health and lower incomes.

What happens if a patient has a physical illness?

For example, if a patient experiences a physical illness while lacking social support, they may become depressed or anxious. Similarly, if a person has depression, they might withdraw from their friends and family and neglect self-care, impacting their physical and social wellness.

Is emotional support a protective factor?

Also, emotional support is considered a protective factor against common mental health disorders. To learn about a client’s social circumstances and how these factors influence their mental and physical health, you might focus on the following: Family relationships. Social support. Marital status.

Present Problem

Identify the primary problem (s), the precipitating factors for the client to seek treatment, and whether or not this is a voluntary client (vs. being compelled by another person or outside agency). Briefly describe these factors in paragraph form.

Other Assessments

In addition to the biopsychosocial assessment you completed for this client, describe the process you will use to complete a clinical assessment for this client, including any other assessments that you feel are pertinent.

Legal, Ethical and Other Considerations

Identify and discuss any ethical and legal ramifications relating to the treatment you are considering. Be sure to indicate whether the ramification is ethical or legal and cite the specific ethical standards or laws that will guide your decisions. Explain how you will address these.

What is biopsychosocial assessment?

Use the Biopsychosocial Assessment Forms as a Guide for a Real Conversation. Most drug and alcohol counselors use a form of some kind to complete the biopsychosocial in one of the first client sessions, usually at an initial intake session. Some forms are better than others.

Why is biopsychosocial model more appropriate?

The biopsychosocial model is much more appropriate in describing the causes and contextualizing the treatment for addiction because it factors in these important dimensions ...

What is a BPS in addiction?

Biopsychosocials (or “BPS” for short) are often one of the first pieces of documentation addiction treatment counselors complete with their patients. Although busy clinicians might dread writing these lengthy and time consuming tomes on each client, the BPS is more than just a mandatory insurance form. BPS’s dig into the patient’s biological, ...

What was George Engel's biomedical model?

When George Engel first introduced the biopsychosocial model, he was offering an alternative to the biomedical model that dominated medicine up until that point. For Engel, the biomedical model, with its sole focus on biology and what was going on in a patient’s body, wasn’t enough to explain disease. This was found to be particularly true ...

Can biopsychosocial assessment form be used as a guide?

It’s worth saying that a biopsychosocial assessment form should never take the place of an in-depth interview with the client. Use the form as a guide for the conversation and never have the patient complete the form themselves.

What is biopsychosocial assessment?

Biopsychosocial assessment is a logical offshoot of Engel’s theory. It is an evaluation that takes into account the biological, social, and psychological aspects of someone’s life when determining what is the cause of their problems. In 1977, a psychiatrist named George Engel created biopsychosocial theory. It posited that health and illness were ...

Why do biopsychosocial assessments take longer?

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, ...

What are psychological factors?

Psychological factors involve a person’s personality, thoughts, and ensuing emotions and behavior. Questions will address current cognitive functioning, coping skills, and mood. An example of a few possible psychology questions follow:

How many goals should a substance abuse treatment plan have?

Typically, a well-written substance abuse treatment plan will have two to three goals to accomplish while in treatment. Unless the treatment stay is short, such as in detox facilities. Keep in mind that along with each goal, you need to write an objective that defines what the patient will do to accomplish the goal, as well as intervention, ...

What is an objective guideline?

A general guideline is that if you cannot actually see the client do something, then it's a goal. A good example of this is patients improving their lives. You can't see that. If you can see the client do something, such as learn new coping strategies, then it is an objective.

What are the steps of EMR?

When you write a treatment plan be sure to use these four steps: Identifying the behavioral definitions/problem statements. Goals.

Is a treatment plan a living document?

It's important for you to remember that once the treatment plan is written it doesn’t end there. The idea is that the treatment plan is treated as a living document, updated regularly throughout the course of treatment, as the client improves and meets target dates on his or her treatment plan.

What is a Biopsychosocial Assessment?

Biopsychosocial assessments are a product of the biopsychosocial model proposed by Dr. George Engel in 1977. Dr. Engel proposed that a person’s well-being is influenced by biological, psychological, and social factors. In layman’s terms, the body and mind are not separate entities.

What is the Purpose of a Biopsychosocial Assessment?

A biopsychosocial assessment helps counselors, psychologists, social workers, therapists, psychiatrists, and other mental health professionals learn about their clients on a number of levels early on in the treatment process while also learning about their subjective viewpoints on a number of different topics, resulting in a more proper diagnosis and effective treatment plan..

What Should Be Included in a Biopsychosocial Assessment?

Mental health professionals typically ask their clients to fill out a biopsychosocial assessment early on in treatment as part of an initial assessment. As the name suggests, there are three main parts in a biopsychosocial assessment template, including:

Streamlining your Biopsychosocial Assessment into an Editable PDF Template

Gathering important biopsychosocial information is crucial to making proper assessments and creating an effective treatment plan. How you collect information can dramatically influence the speed at which you assess and help your client.

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Subjective Assessment

  • Identifying Information and Chief Complaint
    The client is a 40 year old white male who was referred to my care by his sister’s therapist, Dr. Joy. The client’s chief complaint is about the people around him and not himself. He says that his friends, sister, and dad are all “idiots” who have psychological problems. The referring therapist…
  • Current Risk
    The client is currently not a risk to himself. There is some concern for danger to others. At this time I would assess the risk level at high, given his past behavior. There have been incidents where he has coerced women into sexual contact with him. There have also been times when h…
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Mental Status Observations

  • Appearance, Orientation and Insight
    The client’s hygiene is is good. He wore a button down shirt and slacks to our first meeting. His hair and nails were well kept. The client is oriented by four. He has poor insight and is unaware that any of his behavior is problematic.
  • Behavior
    His activity level is normal. His behavior is mostly normal. However, he will hold eye contact for long periods of time in a way that feels intimidating. He will also mutter things under his breath and smile to himself occasionally. Additionally, he became enraged once and yelled at me that I …
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Diagnosis

  • F60.2Antisocial Personality Disorder. The client demonstrates disregard for and violation of the rights of others in a number of ways. He lied to the woman he had a baby with about his name and profession, he manipulated a child into pretending to be his daughter so that he could impress a woman, and he frequently lies to his family. He is irritable and aggressive with his friends and fa…
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Plan

  • Goals
    1. The client will be open to counseling 1. 1.1. Short-term objective: the client will attend one counseling session per week. 1.1.1. Interventions:contracting with the client for counseling attendance. I will ask the client to attend one session per week for the next ten weeks. Increase t…
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Identifying Information

Summary Impression

Client History/Information

Presenting Problem

Problem List/Strengths

Target Problem

Goal Statement

Objectives/Steps to Goal Achievement

Treatment Plan

  • The client’s symptoms fit the criteria for social anxiety disorder, which manifests as fear and anxiety attacks in stressful social environments (Kroenke, 2012). She can benefit from CBT combined with relaxation methods to her manage recent anxiety attacks manifested as impaired speech and heavy breathing during theater classes. Cognitive appraisal...
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Evaluation Plan

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