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, psychological, and social background and inform every part of treatment planning and execution. That makes them a critical piece of the addiction treatment puzzle.

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 for patients in addiction medicine, where every part of a person’s life is touched and influenced by the disease and the recovery process. The biopsychosocial model is much more appropriate in describing the causes and contextualizing the treatment for addiction because it factors in these important dimensions of the patient’s life. 

Today, we’ll look at a few tips and tricks for improving your biopsychosocial assessments and learn how to avoid common mistakes clinicians make in completing the BPS.

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. Look for forms that have robust multiple choice responses to assessment questions like, “What is the patient’s affect?” and “How does the patient respond to the clinician?” More options to choose from are better here to avoid needing to manually write a common patient attribute, like “avoids eye contact.”

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. Weaving the form into natural conversation takes practice but getting the clinical relationship off to a warm and human start is an important part of building a therapeutic alliance with the patient. 

Keep Objective Facts Seperate from Subjective Opinions in your Biopsychosocial Assessment

When writing a BPS, stay conscious of the difference between facts and opinions. 

Facts are incontrovertible truths: the patient’s hands were shaking, the patient identified her uncle as a reliable support person, the patient reports three DUIIs. 

Opinions are interpretations made by the clinician: the patient appears nervous, the patient seemed uncomfortable when she talked about her uncle, the patient appeared embarrassed by her driving history.

In a BPS, as with any other clinical note, an inference or opinion always needs to be qualified with the use of tentative phrases to flag the statement as an opinion or interpretation. It’s important that readers are able to discern what actually happened in a session from the clinician’s perspective on the interaction. 

Master the Use of Tentative Phrases 

As mentioned above, the use of tentative phrases is important for flagging statements in the BPS as opinion when they are not based on fact. 

Instead of “the patient is happy to be back in treatment” try “the patient smiled when she talked about returning to treatment and appeared happy with the decision.” Reading this example, it’s easy to see the clinician's reasoning behind the interpretation (“appeared happy with the decision”) but also learn what actually happened in the session (“the patient smiled when she talked about returning to treatment”). 

Other tentative phrases to try include:

• “The patient appears...”

• “The patient seemed...”

• “Perhaps the patient…”

• “This indicates to this writer that…”

• “This writer believes…”

• “The patient’s response suggests that…”

Mastering the use of these phrases is critical for maintaining the boundaries between fact and opinion in the BPS assessment. 

Not All Biopsychosocial Forms Are Created Equal 

At BehaveHealth, we pride ourselves in intuitive, easy-to-use templates and forms for every part of the addiction treatment process. With our EHR, you can complete a BPS on your computer, on your phone, or on a tablet for maximum flexibility and integration into the clinical environment. 

All the documentation you complete on BehaveHealth’s all-in-one system is readily accessible on the cloud for easy reference wherever the work of addiction treatment takes you. 

Why not get your free trial today and see for yourself how easy it is to write complete, excellent documentation for every client every time using BehaveHealth.