Beyond Symptoms: Seeing the Person As a Whole Through Biopsychosocial Assessment

Mental health care increasingly requires comprehensive and personalized approaches that can capture the full complexity of human functioning. The biopsychosocial assessment offers a structured framework that integrates biological, psychological, and social factors to foster a comprehensive understanding of an individual’s health. The shift in understanding human health from the biomedical model to the biopsychosocial model was initiated by George L. Engel in 1977 with his biopsychosocial theory, which proposed that health and illness can be understood through the interaction of biological, psychological, and social factors. Engel’s biopsychosocial model challenged the reductive perspective on illness and laid the foundations for a more holistic and person-centered approach to healthcare.

The common goal of evidence-based approaches to biopsychosocial assessment is to identify the unique contributions of multiple domains of potential factors to a client’s overall physical and psychological health. Previous clinical assessments have typically sought to determine whether a client’s medical condition is primarily psychological or physical. In contrast, the biopsychosocial assessment, as a multidimensional structure, is shaped by physical, cognitive, emotional, behavioral, and environmental factors at different levels that contribute to the overall clinical assessment and conceptualization of each case (Peterson, 2015). The biopsychosocial approach, which provides a comprehensive assessment of the case, is widely used in the context of many diseases, disorders, or conditions.

In the current therapy sketch, how the biopsychosocial assessment in the field of mental health works will be defined, the dimensions of the biopsychosocial model will be evaluated, and the importance of biopsychosocial assessment in the clinical field will be discussed.

What is the Biopsychosocial Assessment?

Biopsychosocial assessment is a clinical assessment method based on the biopsychosocial model of health and illness, first proposed by George Engel in 1977. As a holistic approach, biopsychosocial assessment is defined as a comprehensive evaluation that examines the complex network of biological, psychological, and social factors contributing to an individual’s mental health. This model emphasizes that no single biological, psychological, or social domain can fully explain human health or illness independently. Instead, these domains interact dynamically to shape the development, manifestation, and course of psychological and medical conditions (Engel, 1977). According to Engel (1977), health and illness arise from the interaction of biological variables, psychological patterns, and social factors. The biopsychosocial assessment acknowledges that these three areas are intricately linked and collectively influence an individual’s mental health (Easton, 2024).

The importance of biopsychosocial assessment has increased significantly with the rise of trauma-sensitive care, culturally competent practices, and interdisciplinary collaboration in mental health. Today, it is recognized as one of the best practice standards in fields such as psychology, psychiatry, social work, and other primary health care services (Borrell-Carrio et al., 2004; Johnstone & Dallos, 2014). Furthermore, biopsychosocial assessment has been adopted by the World Health Organization (WHO) as the foundation of the International Classification of Functioning (ICF). Far from being merely a diagnostic tool, biopsychosocial assessment serves as a dynamic framework throughout the treatment process (from intake to formulation, treatment planning to outcome assessment). This widespread acceptance of the biopsychosocial assessment underscores the model’s nearly universal value in understanding and addressing the complex nature of mental health issues (Easton, 2024).

So, what exactly does a biopsychosocial assessment evaluate? As suggested by the biopsychosocial model, biopsychosocial assessment serves as a structured and integrative framework for gathering and synthesizing detailed information in the biological, psychological, and social domains. Seeking to understand the context and meaning of an individual’s experience, biopsychosocial assessment is typically used during intake interviews, but its application is known to continue throughout the therapeutic process. The components of biopsychosocial assessment, which are addressed in three main dimensions, are as follows (Easton, 2024):

1. Biological Factors

• Physical Health and Medical History: Factors that may affect an individual’s overall physical and mental health, including chronic conditions, injuries, or disabilities, are evaluated.

• Genetic Influences: Considering family medical history and possible genetic predispositions, the role of genetic predispositions in the development of mental health disorders is evaluated.

• Substance Use: The individual’s history of substance use, such as alcohol, drugs, and other medications, and the potential impact of these factors on the individual’s mental health and overall well-being are evaluated.

• Neurobiology: The impact of the brain on the individual’s life experiences is assessed. This includes exposure to substances before birth or maternal stress, head trauma, concussion, or neurological disorders such as epilepsy.

• Pain and Chronic Conditions: Chronic pain conditions that may affect the individual’s mood, energy, and activity levels, the psychological effects of managing ongoing pain, and the impact of this experience on relationships are evaluated.

• Hormonal Effects: Hormonal fluctuations, imbalances, or specific stages (menstrual cycle, pregnancy, menopause, etc.) that may affect the individual’s mood, behavior, and daily functioning are evaluated.

2. Psychological Factors

• Mental Health History: The individual’s previous symptoms, diagnoses, treatments, and coping strategies are evaluated.

• Current Mental Health Symptoms: The individual’s current symptoms are evaluated in terms of frequency, intensity, duration, and degree of impact on daily functioning.

• Emotional Regulation: The individual’s ability to effectively express and manage their emotions, including their ability to cope with stress, anxiety, and other emotional difficulties, is assessed.

• Cognitive Functioning: The individual’s thought patterns, beliefs, and perceptions, as well as their information processing, decision-making, and problem-solving skills, are assessed.

• Trauma History: The individual’s past traumatic experiences, such as abuse, neglect, accidents, or losses, and how these experiences affect the individual’s current functioning are assessed.

• Personality Traits: Basic personality traits that may affect the individual’s behavior, relationships, and overall mood, such as resilience, adaptability, and self-esteem, are assessed.

3. Social Factors

• Family Dynamics: The quality of the individual’s family relationships, communication patterns, support mechanisms, and conflict patterns is assessed.

• Social Support Systems: The strength, quality, and accessibility of the individual’s social networks, including friends, colleagues, and community resources, are assessed.

• Migration and Acculturation: The individual’s migration history, language barriers, acculturation stress, and how adapting to a new cultural context affects their mental health and social identity are assessed.

• Cultural Background: How the individual’s cultural identity, values, and beliefs can shape their mental health, therapy process, and overall perception of life is assessed.

• Discrimination and Othering: The individual’s experiences of discrimination, othering, or stigmatization related to their race, gender, sexual orientation, disability, or other aspects of their identity are assessed.

• Environmental Stress Factors: Environmental factors that may affect the individual’s mental health and overall well-being, including socioeconomic status, social security and stability, exposure to substance use, access to health services, housing stability, and living environment, are assessed.

• Legal Issues and Criminal History: Past and present legal issues that may affect an individual’s mental health and access to resources, such as custody cases, criminal charges, probation, or involvement with agencies such as Child Protective Services, are assessed.

Understanding what a biopsychosocial assessment entails and identifying its three core components (biological, psychological, and social factors) provides an important foundation for its application in the clinical setting. In a therapeutic setting, biopsychosocial assessment is not merely a diagnostic tool; it is also a dynamic method that shapes the therapeutic alliance, informs case conceptualization, and guides intervention strategies. When integrated with models such as the 4Ps (predisposing, precipitating, perpetuating, and protective factors), biopsychosocial assessment becomes a powerful mechanism for providing contextually sensitive and ethically sound mental health care. The following section will address how biopsychosocial assessment is applied in the therapeutic field.

Using Biopsychosocial Assessment in a Therapy Setting

Biopsychosocial assessment is a fundamental tool in the therapeutic setting, offering clinicians a well-structured yet flexible approach to understanding the full range of a client’s functioning. More than just a diagnostic tool, biopsychosocial assessment serves as a clinical compass throughout the therapeutic process. Additionally, in the therapeutic setting, biopsychosocial assessment is a powerful method that shapes treatment planning, client collaboration, and outcome evaluation. Therapists can create a dynamic case formulation that integrates biological, psychological, and social domains using the 4P model, providing information for diagnosis, treatment planning, and ongoing clinical decision-making processes.

Enhancing Therapeutic Assessment Through the 4P Factor Model

The 4P factor model helps clinicians separate and analyze the information they collect through a psychosocial assessment into clinically meaningful components (Macneil et al., 2012; Astier, 2023):

1. Predisposing Factors: These factors include historical or internal vulnerabilities that increase the likelihood of developing a psychological problem. These may include medical and psychiatric history, family history, temperament genetics, and chronic social stressors. Predisposing risk factors increase the likelihood of a client developing a specific mental health disorder, but do not guarantee it. In this context, the question to ask might be, ‘’What factors contributed to this client’s problem throughout their life?’’

Examples: Family history of physical illness, mental disorder (e.g., schizophrenia), genetics.

2. Precipitating Factors: Precipitating factors are typically related to the situation that brought the client to therapy. These are sudden events that trigger the onset of symptoms or distress, such as a recent loss, trauma, or work stress. These factors often arise in a social and psychological context and help explain the timing of the client’s referral. At this point, the question to ask might be, ‘’What prompted the client to decide to start therapy?’’

Examples: Bullying, catastrophic events (forest fires, floods, pandemics, etc.), and a significant increase in stress levels.

3. Perpetuating Factors: These factors refer to elements that perpetuate or exacerbate the problem over time. These may include the severity of the patient’s condition, adjustment issues, and unresolved predisposing factors that create and perpetuate the problem.  

Examples: Unresolved triggering factors such as abusive relationships, substance abuse, unsupportive environments, and ongoing bullying.

4. Protective Factors: Protective factors refer to the client’s strengths, resources, or support systems that can increase their resilience and aid in their recovery. These factors can reduce or prevent the onset and recurrence of a mental health disorder.

Examples: Self-respect, education/intelligence, healthy habits, financial stability, and having strong social support systems such as family and friends.

Integrating the 4P Factor Model into the Biopsychosocial Assessment

Intake Session: Therapists typically begin therapy with a structured biopsychosocial assessment during intake. This involves open-ended and structured questions that allow for the exploration of biological, psychological, and social factors relevant to the client. By exploring these three areas and identifying the relevant 4P factors, the therapist gains a comprehensive understanding of the client’s current concerns and strengths (McGoldrick et al., 2008). Furthermore, the biopsychosocial assessment, which integrates the 4P factor model, forms a case formulation that serves as a working hypothesis regarding the causes and maintenance of the client’s difficulties and guides treatment (Eells, 2015).

Individualized Treatment Planning: The information obtained from the biopsychosocial assessment conducted by integrating the 4P factor model helps design a treatment plan with the following characteristics (Sperry, 2014):

• Targeting perpetuating factors through interventions tailored to the client’s needs
• Built on protective factors to increase resilience
• Addressing predisposing vulnerabilities through trauma-informed approaches
• Helping the client process and resolve precipitating events through supportive or insight-focused techniques
• Targeting not only symptoms but also contributing systemic factors

A treatment plan customized to the client’s needs and incorporating the above features increases client participation, supports self-efficacy, and improves treatment compliance (Norcross & Wampold, 2011).

Monitoring Progress and Outcomes: The biopsychosocial assessment is not a one-time process. Throughout the therapy process, clinicians can refer back to the BA and 4P framework to:

• Reassess psychosocial changes
• Evaluate the effectiveness of interventions
• Adjust treatment goals as new stressors or supports arise
• Use standardized measures (PHQ-9, GAD-7, etc.) to monitor biological or psychological domains in addition to client self-reports

Additionally, answers to the following questions may be sought:

• Have protective factors (e.g., employment) been strengthened?
• Are perpetuating factors (e.g., substance use) being reduced?
• Have new precipitating stress factors emerged?

The repeated use of this biopsychosocial assessment ensures that therapy remains sensitive and contextually grounded.

How is a Biopsychosocial Assessment Structured?

Biopsychosocial assessment requires a systematic approach to examine and understand the client’s unique circumstances comprehensively. Some important points regarding how biopsychosocial assessment should be structured are as follows (Easton, 2024):

• Preparing for assessment: The therapist creates an environment that supports open communication with the client, one that is sincere yet maintains confidentiality. They gather information about the client using various materials such as assessment tools and questionnaires.
• Building a relationship: The therapist creates a non-judgmental environment by actively listening to the client, showing empathy, and adopting a collaborative stance. They ask open-ended questions or use reflective listening to learn about the client’s unique experiences and perspectives.
• Gathering information: The therapist asks the client more specific questions to elaborate on the general information they have about the client, obtaining information on important areas such as the intensity, frequency, and onset of symptoms.
• Observing nonverbal cues: The client’s body language, facial expressions, and tone of voice can convey important messages and are therefore carefully evaluated. By observing nonverbal cues, the therapist can obtain critical information about the client’s emotional state and level of participation in the assessment process.

Takeaways:

• Biopsychosocial assessment considers the client’s health status not only in one dimension but in a multidimensional way, taking into account physical, emotional, cognitive, and environmental factors.
• Unlike the one-dimensional assessments used in the past, the biopsychosocial model is a powerful tool for understanding the clinical picture more accurately and personalizing the treatment process.
• Therapists can understand the client’s functioning in a multidimensional and dynamic way thanks to the biopsychosocial assessment supported by the 4P model.
• An effective biopsychosocial assessment requires establishing a trust-based relationship with the client and understanding their individual experiences holistically.

References

1. Easton, V. C. (2024). Writing a Biopsychosocial Assessment: tips, examples, and templates for therapists. https://www.blueprint.ai/blog/writing-a-biopsychosocial-assessment-tips-examples-and-templates-for-therapists 
2. Engel, G. L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129–136. https://doi.org/10.1126/science.847460  
3. Borrell-Carrió, F., Suchman, A. L., & Epstein, R. M. (2004). The biopsychosocial model 25 years later: Principles, practice, and scientific inquiry. Annals of Family Medicine, 2(6), 576–582. https://doi.org/10.1370/afm.245 
4. Johnstone, L., & Dallos, R. (2014). Formulation in psychology and psychotherapy: Making sense of people’s problems. Routledge. https://doi.org/10.4324/9780203380574 
5. Peterson, A. L., Goodie, J. L., & Andrasik, F. (2015). Introduction to biopsychosocial assessment in clinical health psychology. In F. Andrasik, J. L. Goodie, & A. L. Peterson (Eds.), Biopsychosocial assessment in clinical health psychology (pp. 3–7). The Guilford Press. https://psycnet.apa.org/record/2015-10562-001 
6. Macneil, C. A., Hasty, M. K., Conus, P., & Berk, M. (2012). The therapeutic alliance: Is it necessary or sufficient to engender positive outcomes? Acta Neuropsychiatrica, 24(2), 95–98.
7. Astier, A. L. (2023, January 21). The 4P factor model and its purpose in psychological medicine. — Andréas Astier. Andréas Astier. https://www.andreasastier.com/blog/the-4p-factor-model-and-its-purpose-in-psychological-medicine 
8. McGoldrick, M., Gerson, R., & Petry, S. (2008). Genograms: Assessment and intervention. W. W. Norton & Company. 
9. Eells, T. D. (2015). What is an evidence-based psychotherapy case formulation? https://www.researchgate.net/publication/292101575_What_is_an_evidence-based_psychotherapy_case_formulation 
10. Norcross, J. C., & Wampold, B. E. (2011). Evidence-based therapy relationships: Research conclusions and clinical practices. Psychotherapy, 48(1), 98–102. https://doi.org/10.1037/a0022161 
11. Sperry, L. (2014). Biopsychosocial Case Formulation. Routledge. 

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