assignment 4 biopsychosocial approach in counselling

• Last edited on January 27, 2024

Biopsychosocial Model and Case Formulation

Table of contents, diagnosis versus formulation, the formulation table, "jane doe", biological and social factors, psychological factors, completed table, method 1 (sequential), method 2 (narrative), method 3 (advanced), method 4 (chronological), common phrases to use, do's and dont's, another example, "templates".

The Biopsychosocial Model and Case Formulation (also known as the Biopsychosocial Formulation ) in psychiatry is a way of understanding a patient as more than a diagnostic label. Hypotheses are generated about the origins and causes of a patient's symptoms. The most common and clinically practical way to formulate is through the biopsychosocial approach, first described in 1980 by George Engel. [1] [2] Biopsychosocial formulation combines biological, psychological, and social factors to understand a patient, and uses this to guide both treatment and prognosis. Your formulation of a patient evolves and changes as you collect more information. Formulation is like cooking, and there is no 'right' or 'wrong' way to do it, but most get better over time with increasing clinical experience.

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Diagnosis is not the same as formulation! In mental health, when there is a group of consistent symptoms seen in a population, these symptoms can be categorized into a distinct entity, called a diagnosis (this is what the DSM-5 does). For example, we diagnose someone with a major depressive episode if they meet 5 of the 9 symptomatic criteria. However, formulation tells us how the person became depressed as a result of their genetics , personality , psychological factors , biological factors, social circumstances ( childhood adverse events and social determinants of health ), and their environment.

You are probably already formulating, but just don't know it. Like most things in medicine, there are multifactorial causes of diseases, illnesses, and disorders. For example, type II diabetes does not develop because of a single pathophysiological cause. The patient may have a strong family history of the disease, a sedentary job, environmental exposures, and/or a nutritionally-poor diet. These factors all combine to cause the person to develop diabetes. Understanding how each factor contributes to a disease can better guide treatment decisions. In psychiatry, formulation appears more complicated because human behaviour and the brain itself is extraordinarily complex. However, like with anything, the more you practice, the better you will become at formulating.

What Are You Formulating?

Why is a biopsychosocial approach important, formulation in a nutshell.

The biopsychosocial model considers the “4 Ps” for each of the biological, psychological, and social factors:

• Predisposing factors are areas of vulnerability that increase the risk for the presenting problem. Examples include genetic (i.e. -family history) predisposition for mental illness or prenatal exposure to alcohol.
• Precipitating factors are typically thought of as stressors or other events (they could be positive or negative) that may be precipitants of the symptoms. Examples include conflicts about identity, relationship conflicts, or transitions.
• Perpetuating factors are any conditions in the patient, family, community, or larger systems that exacerbate rather than solve the problem. Examples include unaddressed relationship conflicts, lack of education, financial stresses, and occupation stress (or lack of employment)
• Protective factors include the patient’s own areas of competency, skill, talents, interest and supportive elements. Protective factors counteract the predisposing, precipitating, and perpetuating factors.

The “4 Ps” can be laid out in a 3 x 4 table to systematically do formulation and identity factors. Note that this table is extremely comprehensive and long, and not everything will (or should!) apply to your case. It is important to remember that not everything will fit neatly into each box. For example, many precipitating and perpetuating factors may overlap and fit in other boxes. Use this table as a general guide, but don't memorize it for the sake of memorizing it!

Biopsychosocial Model

Filling out the table.

• As you can see in the table above, it's a lot of questions to ask and a lot of things to think about!
• Let's do a simplified formulation for the patient (Jane Doe) below. The image ( figure 1 ) provides a guide on how to put information into the formulation table.
• These psychological symptoms/factors are then observed by the clinician to give a psychiatric diagnosis.
• This is why the psychological section of the table is filled last, so we can understand what biological and social factors led to the development of these symptoms.

• Jane Doe is a 30-year-old female who presents to the emergency room with acute suicidal ideation and self-harm
• Jane has been working at a start up company for the past 2 years. She was suddenly fired from her job today due to conflicts at work with co-workers and being late at work several times from sleeping in. After being told she was fired from her job, she went home and self-harmed to cope with the distress of this loss. She also drank 10 beers prior to arriving in the hospital. She subsequently planned to overdose on her medications. A concerned best friend called and talked to her this evening, and brought her to the hospital. Her mood was stable prior to this job loss, and she had no self-harm or suicidal thoughts in the past 1 year.
• Increasing alcohol use for the past 3 months, drinking up to 5 beers per day.
• Sertraline (Zoloft) 75mg PO daily
• She has a past history of borderline personality disorder , depression , and alcohol use disorder (moderate). She used to be a soccer player and has a history of multiple concussions. She does have a psychiatrist that she sees every month. She previously completed a course of dialectical behavioural therapy , which was helpful.
• Depression and bipolar disorder on maternal side of her family. There is a history of alcohol use disorder on paternal side.
• Born in Canada. University-educated. There was a parental divorce at age 5. She describes an invalidating childhood, where parents did not acknowledge or praise her. She experienced sexual abuse and trauma at age 12. She is in a 2-year relationship with a male partner, and there have been recent arguments about the direction of their relationship. She describes a long-standing fear of being abandoned in relationships, and reports having very intense relationships with friends/family. Financially, she is struggling to pay rent and living from paycheque-to-paycheque. Developmentally, there may have been some speech delay . Collateral information from the patient's older brother describe her childhood temperament as being avoidant and fearful of her parents.

Steps 1 and 2

Sample formulation for jane doe.

Now that you've filled in the easy parts from the history, the hardest part is conceptualizing the predisposing social factors (Step 3), and all of the psychological factors (Steps 4, 5, 6, 7). This is where you'll need to be creative and also think more in-depth about your patient. Ideally, each step should flow logically and intuitively into the next based on your framework, as you'll see in our case of Jane Doe. Having a framework for understanding of different psychological treatments and psychological theories can be helpful in making your psychological formulation flow intuitively (e.g. - attachment theory , cognitive behavioural therapy , dialectical behavioural therapy , interpersonal therapy , psychodynamic therapy ). However, this can be done intuitively even without an in-depth understanding of these frameworks (we don't need to be Freud to do this). The more cases you go through (and more of the sample formulations below) the more comfortable you will be with formulating!

Steps 3, 4, 5, 6, and 7

Jane doe's formulation, completed biopsychosocial formulation table, completed formulation of jane doe, presenting your formulation.

You've got your table all filled out now. Now what? How do you present all this information and data? Remember there is no “right” or “wrong” way to present your formulation. But the most important thing about formulation is that it should be intuitive and flow logically. Some different presentation styles are suggested here.

The “4 Ps” formulation table can be a very rigid and systematized way of presenting a formulation. At its most basic, you could present each box sequentially and describe each factor. Most learners will use this method as it is the most “simple.” It is usually presented as Predisposing → Precipitating → Perpetuating → Protective factors. As you get better and more expert at formulating, you may not need to use this rigid structured format, and instead, will be able to present a more intuitive and organic formulation of the patient instead (see other methods below).

• Brief summarizing statement that includes demographic information, chief complaint, and presenting problems from patient's perspective and signs and symptoms (onset, severity, pattern)
• Predisposing factors
• Precipitating factors
• Perpetuating factors
• Strengths and protective factors
• Integrative statement: how these factors interact to lead to the current situation and level of functioning, prognosis, and potential openings for intervention

Example: 4 Ps Table Formulation of Jane Doe

• Jane Doe presents with a diagnosis of borderline personality disorder and history of depression. She presents to hospital today with acute suicidal ideation and self-harm after being fired from her job.
• Predisposing factors : Her predisposing biological factors include a family history of mental disorders and substance use, concussion history, and a fearful/anxious temperament at birth. Her predisposing social factors include a history of sexual trauma at a young age, and early parental divorce. These led to her predisposing psychological factors, including a history of invalidation by her parents, and fears of abandonment during childhood.
• Precipitating factors : Her precipitating biological factors include a 3-month history of increasing alcohol use. Her precipitating social factors is her being fired from her current job. These led to her precipitating psychological factors, which resulted in her underlying feelings of abandonment and invalidation re-activated after being fired from work.
• Perpetuating factors : Her perpetuating biological factors include being on a subtherapeutic dose of her medication, and her ongoing alcohol use. Her perpetuating social factors includes her ongoing relationship conflicts and financial stressors. Her perpetuating psychological factors include her lack of adaptive coping strategies and ongoing self-harm.
• Strengths and protective factors : She is medically healthy, and has previously responded well to therapy. She also is supported by a good friend, and sees a psychiatrist regularly.
• Integrative Statement : The acute stressor of losing her job has re-activated the psychological processes described above. The patient is psychologically minded and thus would benefit from treatment with dialectical behavioural therapy. Her medications could also be further optimized as well. Overall, her prognosis is good due to her protective factors as mentioned above.

The narrative formulation of the patient is a less rigid presentation structure where you may not choose to present everything in the 4 Ps table, and instead focus on the key factors that you think are relevant:

• [Patient] presents with a [diagnosis]. They are biologically predisposed because of [reasons]. They struggle with the following [psychological difficulties]. Their underlying temperament is [temperament], which further exacerbates the symptoms.
• Childhood/adult trauma (if any)
• Attachment style
• About themselves
• About others
• About the world
• (i) death of their spouse
• (ii) stopping medications
• (iii) loss of job
• (iv) re-experiencing of trauma
• They have the following: [protective factors]

Example: Narrative Formulation of Jane Doe

• Jane Doe presents with a diagnosis of borderline personality disorder and history of depression. She is biologically predisposed, with a family history of depression and alcohol use disorder in her immediate family members. She struggles with the following psychological difficulties, including fears of abandonment. Her underlying temperament is anxious, which further exacerbates her symptoms.
• Her underlying history of experiencing trauma and sexual abuse at a young age
• A history of invalidating experiences in childhood
• That she is not deserving of love or close relationships, a core belief of her being “unlovable”, and that self-harm is the main way of coping with stressors
• That others may leave or abandon her any time, increased rejection sensitivity, and a future fear of being rejected
• That the world can be a fearful and scary place
• After being fired from her job, she experienced strong feelings of rejection, and was unable to cope with this major stressor. This may have reactivated/exacerbated her emotional dysregulation, and resulted in negative coping styles such as her self-harming and suicidal ideation. She also appears to use alcohol as a way of managing distressing emotions, but does not have any psychological coping strategies. This has further exacerbated her alcohol use disorder.
• She has the following protective factors, including a supportive psychiatrist and friend. She has also previously responded well to psychotherapy and appears to be psychologically-minded.

A much more advanced and nuanced presentation might be using a more comprehensive formulation that integrates the 4Ps formulation through multiple lenses (e.g. - Eriksonian developmental stages , psychodynamic defenses , and dialectical behavioural ):

• Current stressors, plus salient developmental history
• “The patient presents at this time with [problem and symptoms], in the context of [situation and stressors]”
• Genetics, temperament, medical history, substances, medications
• “The patient has the following [genetic vulnerabilities, medical history]”
• “The patient grew up in a family characterized by [factors], with a caregiver who was [distant/available/invalidating]”
• “ Attachment was likely [secure/insecure/disorganized] given [developmental history]”
• “The patient may have had difficulty in [stage of development], and this is reflected in [examples from adult relationships]
• “It appears that the patient may have struggled with conflicts in early life. It also appears they may have had difficulty with [drives], stemming from [psychoanalytic concept]
• Control/regulation of drives
• “These experiences impacted the patient's view of themselves as being [view of self], and this has continued into adulthood based on [experiences].”
• “The patient appears to have adopted [defense mechanisms] as coping strategies by early adulthood, and these have continued on…”
• “The patient's interpersonal relationships appear to be [give examples of patterns of relationships]”
• These underlying factors may have precipitated the patient's [current presentation]. These symptoms have been maintained by [psychological factors/personality factors], and [social/environmental factors]
• “We would anticipate when engaging in treatment, the patient may have [resistance/transference/countertransference]. However, patient has the following [protective factors], which may be a good prognostic factor. Based on these factors, the following [treatment and management] would be the most helpful for this patient.

Example: Advanced Formulation of Jane Doe

• Jane Doe is a 30-year-old female who presents with acute suicidal ideation in the context of a job loss. She notably has a past history of childhood trauma and abuse.
• The patient has genetic vulnerabilities for mental illness in her family history, a history of anxious temperament, ongoing substance use, and subtherapeutic medication levels.
• She has several early developmental and pathogenic psychological factors, including growing up in a family characterized by invalidation, with parents who were distant and unavailable. This likely led to an attachment style that was likely insecure and disorganized. Due to her history of abuse at age 12, she may have struggled with identity versus role confusion during that Eriksonian stage of psychosocial development. As she was unable to develop a sense of self and personal identity, these psychological factors are reflected in her adulthood with unstable relationships, and fears of abandonment. This has led to her adulthood self-perception of being unworthy of being loved, a constant fear of rejection, and increased rejection sensitivity. The patient appears to have adopted self-harming as a primitive coping strategy by early adulthood, and these have continued on in adulthood.
• Precipitating and perpetuating factors: the stressor of losing her job has reactivated these more primitive defense mechanisms and coping strategies. These symptoms have been further perpetuated by the personality factors and traits described above, and her ongoing financial stressors. Her ongoing alcohol use is another example of a maladaptive coping strategy.
• We would anticipate when engaging in treatment, the patient may have difficulties with using primitive defense mechanisms. However, the patient has protective factors including psychological mindedness and previous response to therapy, which is a good prognostic factor. Based on these factors, dialectical behavioural therapy would be the most helpful for this patient.

Yet another way to present a formulation is in chronological order, starting from birth until present time:

• Genetics (family history)
• Birth (issues at birth, developmental history, developmental stages)
• Childhood (attachment style, neurodevelopment, milestones, trauma)
• Adolescence (relationships, trauma, school performance, substances)
• Adulthood (occupation, relationships, children, environment, stressors)
• Integrative statement (of how genetics, birth, childhood, adolescence, and adulthood factors contribute to current presentation, and how this directs your treatment/management)

Having certain common phrases to use can be helpful to structure your presentation. Here are some examples:

• “From a biological perspective, the patient is vulnerable because…”
• “The patient's early childhood and developmental history suggest…”
• “Used substances as a coping style in [the past], and now this is occurring again (or there is a relapse) due to [social factor].”
• “Used substances as a coping style in [the past], and now this is occurring again (or there is a relapse) due to [psychological vulnerability].”
• “I wonder if… [psychological factor] is contributing to [current symptoms/struggles]”
• Use your own words and personal style
• Tell a story and narrative that is unique to your patient
• Be specific and demonstrate your understanding of the patient as a person and not a diagnosis
• Use words like precipitating, protective, and perpetuating factors to anchor your listener
• Focus on the most salient features and be concise
• Try and use a psychological theory (but only if you understand it)
• Be confident in your presentation!
• Include too much extra detail
• Try to be perfect only to overwhelm yourself
• Be generic (your formulation needs to be unique to your patient)
• Tell the patient's whole story all over again
• Mention life events or trauma without an understanding of its meaning or impact
• Try to formulate a “grand unified theory” of the patient and over-reach with your theory (if it doesn’t fit, it doesn’t fit! And that's okay!)
• Cover every box in the 4 Ps just for the sake of doing it (not all boxes will always apply!)

Beyond Basic Formulation

A good formulation should be integrative, and let you understand how all of the patient's factors interact to lead to the current situation. This gives you a sense of their current level of functioning, prognosis, and guides your direction for treatment and management decisions.

A good biopsychosocial formulation allows you to come up with a comprehensive and holistic treatment plan for your patient. Here is an example of a set of treatment recommendations for Jane Doe:

• What level of care is required (outpatient or inpatient)?
• Jane is able to articulate a safe plan to stay with a friend, and is suitable for outpatient care
• Jane might benefit from an increase of her sertraline from 75mg to 100mg and beyond (maximum dose of 200mg), for her mood dysregulation and depressive symptoms
• Jane might benefit from the use of anti-craving medications such as gabapentin or acamprosate to reduce her cravings for alcohol use
• Dialectical behavioural therapy (DBT) would be the most appropriate for Jane
• Jane would also benefit from motivational interviewing for her alcohol use
• Long-term, Jane might also benefit from a more in-depth understanding of how her past trauma affects her present self and symptoms. This could be achieved with more specific and in depth trauma therapy, but given the acuity of her symptoms, this is something that would follow after DBT.
• Jane could benefit from accessing support from her company's HR department to understand what options she has after her job termination
• Substance use groups such as Alcoholic's Anonymous
• Increasing connections to her friends and social supports

For good measure, here is another sample formulation for someone with a diagnosis of schizophrenia . Note that in this example, since the precipitating cause for acute psychosis (also applies to manic episodes ) is more “biological,” it may be harder to identify underlying psychological factors (but that's OK too – even the most “biological” psychiatric disorders can often be precipitated by psychosocial stressors). Again let's fill out the easiest parts of the table first:

Sample Formulation for Schizophrenia (Initial)

Now here is one potential example of a predisposing social and psychological formulation of psychosis (again, there are no right or wrong ways to formulate, it depends on the patient you have in front of you!)

Example of A Possible Psychological Formulation of Psychosis/Schizophrenia

Here's what the completed table would look like with the psychological factors incorporated.

Completed Formulation for Schizophrenia (Initial)

As you do more formulation, you will notice that patients tend to present in “templates,” that is, certain diagnoses tend to follow a certain common theme of predisposing, precipitating, and perpetuating factors. The more you formulate, it can be helpful to have a rough template of different formulations for different diagnoses (e.g. - depression, self-harm, mania/psychosis, anxiety, etc.) It will make your job of formulating much easier.

The following readings below are excellent resources to further develop your formulation skills:

• Selzer, R., & Ellen, S. (2014). Formulation for beginners. Australasian Psychiatry, 22(4), 397-401.
• Winters, N. C., Hanson, G., & Stoyanova, V. (2007). The case formulation in child and adolescent psychiatry. Child and Adolescent Psychiatric Clinics, 16(1), 111-132.
• Weerasekera, P. (1993). Formulation: A multiperspective model. The Canadian Journal of Psychiatry, 38(5), 351-358.

Beyond the Biopsychosocial Model

• Kendler, K. S. (2012). The dappled nature of causes of psychiatric illness: Replacing the organic–functional/hardware–software dichotomy with empirically based pluralism. Molecular psychiatry, 17(4), 377-388.

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Understanding the Biopsychosocial Model of Health and Wellness

A holistic approach to well-being

Dr. Amy Marschall is an autistic clinical psychologist with ADHD, working with children and adolescents who also identify with these neurotypes among others. She is certified in TF-CBT and telemental health.

Steven Gans, MD is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital.

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• The Three Aspects of the Biopsychosocial Model

How the Biopsychosocial Model Impacts Mental Health

• Criticism of the Model

How Healthcare Professionals Use the Biopsychosocial Model

How clients and patients can use the biopsychosocial model.

The biopsychosocial model is an approach to understanding mental and physical health through a multi-systems lens, understanding the influence of biology, psychology, and social environment. Dr. George Engel and Dr. John Romano developed this model in the 1970s, but the concept of this has existed in medicine for centuries.

A biopsychosocial approach to healthcare understands that these systems overlap and interact to impact each individual’s well-being and risk for illness, and understanding these systems can lead to more effective treatment. It also recognizes the importance of patient self-awareness , relationships with providers in the healthcare system, and individual life context.

Dr. Akeem Marsh, MD , physician and author of Not Just Bad Kids , described the biopsychosocial model as “at its core, centering around social determinants of mental health in connection with the ‘standard’ biomedical and psychological models. One of the more common ways in which it is represented when using the model is through the four ‘Ps’ of case formulation: predisposing, precipitating, perpetuating, and protective factors.”

Learn more about how providers can use the biopsychosocial model to offer holistic care and how clients and patients can benefit from this approach.

What Are the Three Aspects of the Biopsychosocial Model?

When understanding an individual’s physical and mental health through the biopsychosocial model, we consider physiological factors such as genetics and illness pathology (biological); thoughts, emotions, and behavior (psychological); and socioeconomic components, social support, and culture (social). How do each of these components inform the model as a whole?

“Biology” refers to our genetics , physical health, and the functioning of our organ systems. Our physical well-being impacts our mental health for multiple reasons. First, our brain is an organ and can become unwell just like any other organ. Second, physical health conditions can wear on mental health. For example, chronic pain can lead to symptoms of depression.

Additionally, just like we can have genetic predisposition to a physical disability, mental health has genetic roots as well. According to Dr. Marsh, “Genetics are the most basic level by which mental health is influenced, and on some level has an impact for everyone.” In other words, “Whatever the phenotypical expression, genetics does play a role to some degree.” The expression is in turn influenced by the environment.

Psychological

Mental health is health, and one’s psychological well-being impacts both mental and physical health. Unhealthy and maladaptive moods, thoughts, and behaviors can all be symptoms of mental health conditions, and in turn can contribute to our overall health. Mental health and behavior can be cyclical; for example, an individual who self-isolates as a symptom of depression may experience increased depressive symptoms as a result of isolation.

Routine physical activity is known to promote positive mental wellness, while inadequate or excessive physical activity can contribute to different types of mental health struggles.

Addressing these symptoms is key in improving mental health.

Dr. Marsh shares the impact of external factors on health: “The expression [of genetics] is in turn influenced by environment.” Changes in one’s environment can impact mental health, both positively and negatively. In the previous example of depression and isolation , individuals who have appropriate social support experience fewer mental health issues compared to those without this support.

An individual who is struggling with their mental health might need social support and environmental changes just as much as they need therapy or medication intervention for their symptoms.

Traditionally, healthcare has focused primarily on the medical and biological side of the patient’s needs, and mental health care has focused on the psychological side. While it makes logical sense to address manifesting symptoms, a holistic approach to care that aims to address the social as well as the psychological and biological contributions to illness can be more health-promoting.

Sometimes, for instance, addressing an underlying social need or environmental stressor can improve mental health more effectively than other psychological or biological treatments. This may allow for less-invasive treatments and interventions, and it can improve the individual’s well-being in a way that non-holistic models overlook.

Criticism of the Biopsychosocial Model

Although many providers support a holistic approach to care and implement the biopsychosocial model in practice, like any model it has limitations. Dr. Marsh notes that there are concerns about its evidence backing: “Some people believe that [the biopsychosocial model] is not scientific, as in it has not quite met the ‘gold standard’ of being validated through multiple randomized trials, as it is a uniquely challenging study prospect.” How can researchers study controlled variables in a model that requires holistic care that takes individual needs into account?

At the same time, the model has many strengths and can benefit patients in the healthcare and mental health systems: “It has been researched extensively and shown positive results when applied in different ways,” Dr. Marsh said.

Mental health professionals who utilize the biopsychosocial model in practice include extensive medical history, family history, genetics, and social factors in assessments in addition to psychological information.

Additionally, they use this information to ensure that all of the client’s needs are met , as many medical issues can manifest with mental health symptoms. Therapy services to treat, for example, depression caused by an under-functioning thyroid is unlikely to be effective.

When adopted appropriately, health professionals conceptualize patients that they work with in a broad context that attempts to understand and see patients as a whole person—complex human being with nuance, so much more than just a cluster of symptoms or diagnosis.

This model lets providers see the whole person beyond their presenting symptoms.

While the biopsychosocial model has its place in the healthcare and mental healthcare systems, individuals might also implement tenants of this model in their own lives. This means being aware of how environmental factors impact their mental and physical health, as well as how their genetics and medical history in turn influence behaviors, thoughts, and emotions.

It can help individuals better understand themselves as complex, whole beings as well. “I believe that [the biopsychosocial model] could enhance their self-awareness and understanding of themselves, along with broadening their personal sense of what issues or challenges may be going on with them," says Dr. Marsh.

Engel GL. The need for a new medical model: a challenge for biomedicine .  Science . 1977;196(4286):129-136. doi:10.1126/science.847460

Soltani S, Kopala-Sibley DC, Noel M. The co-occurrence of pediatric chronic pain and depression: a narrative review and conceptualization of mutual maintenance .  The Clinical Journal of Pain . 2019;35(7):633-643. doi:10.1097/AJP.0000000000000723

Alsubaie MM, Stain HJ, Webster LAD, Wadman R. The role of sources of social support on depression and quality of life for university students .  International Journal of Adolescence and Youth . 2019;24(4):484-496. doi:10.1080/02673843.2019.1568887

By Amy Marschall, PsyD Dr. Amy Marschall is an autistic clinical psychologist with ADHD, working with children and adolescents who also identify with these neurotypes among others. She is certified in TF-CBT and telemental health.

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Home > Blog > How to Write a Biopsychosocial Assessment (With Template) - Mentalyc

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How to Write a Biopsychosocial Assessment (With Template) - Mentalyc

Ann Dypiangco, LCSW

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You're not alone if you're a therapist who feels utterly lost when writing a new client's biopsychosocial (BPS) assessment. Writing this report is more time-consuming and arguably more emotionally intimidating than other  types of clinical documentation . Progress notes like  GIRP  or  SOAP  notes tend to be shorter and capture smaller time frames. Whereas BPS assessments are longer, more comprehensive in scope, and span the length of a client's life and family history.

The BPS assessment is vital to the client's chart and treatment and serves many purposes. It provides documentation of symptomology and helps determine if a client meets the criteria for a diagnosis. It also lays out a detailed understanding of an individual's physical, psychological, and social aspects, which helps a clinician develop a holistic case formulation and targeted treatment plan. Given that the BPS assessment is the most lengthy and comprehensive piece of documentation in a client's chart, it is the document most likely to be read by other service providers, such as psychiatrists and future therapists, to inform their care.

This blog post will dive into Biopsychosocial Assessments and answer therapists' common questions. Questions like…

• What information is included in a Biopsychosocial Assessment?
• How to perfectly format a Biopsychosocial Assessment?

How can I make this process less time-consuming?

What tips should i keep in mind while writing a biopsychosocial assessment.

By the end of this blog post, you'll feel less overwhelmed, be secure in your understanding of how  HIPAA-compliant technology can make this process much easier ,  and be ready to dive into the world of biopsychosocial assessment writing.

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What to Include in a Biopsychosocial Assessment? ( 5 Ps in biopsychosocial model)

Just like clients on your caseload, every BPS assessment is different. As you may have guessed from the document's name, the biopsychosocial assessment includes evaluating the client’s biological, psychological, and social aspects of life. There are specific key points you'll want to hit in every report. Additionally, if you're working for an agency or writing the BPS assessment as part of a legal proceeding, confirm if specific requirements must be included to be accepted by the involved institutions.

A common framework for writing a BPS assessment incorporates the 5 P's of case formulation (Macneil et al., 2012). The 5 P's are…

Presenting Problem  - This is the primary complaint or reason the client has come to treatment in the first place and typically means describing what mental health symptoms they are experiencing. Documenting symptoms includes information such as symptom onset, duration, intensity, and frequency.

The presenting problem can also include life stressors that a client faces that put them at risk for future impairment, even if they are not currently experiencing mental health symptoms. An example of this is a child whose parents are getting a divorce. The child has not shown signs of distress, but the parents are seeking treatment for the child. They know the divorce will create upheaval in the child's life and want to be proactive by providing a safe, objective third party for the child to share their feelings with.

Some clients are not attuned to the risk or impairment caused by their symptoms or cannot give an accurate report due to their developmental level or severe symptomology. In these cases, it is advisable to seek information from reliable outside sources, such as parents, psychiatrists, or hospital discharge paperwork, to include in the BSP assessment.

The biopsychosocial assessment may serve as legal protection to the therapist in a case where the client goes on to cause harm to themselves or others. Therefore, It is wise to document a safety risk assessment in this section. Even if a client denies suicidal ideation or thoughts of self-harm, it is essential to note this in the response.

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Predisposing Factors  - These factors in a client's life contribute to the presenting problem and can include genetic, biological, or environmental influences and past childhood experiences.

A comprehensive BPS assessment touches upon the following predisposing factors:

• History of previous mental health symptoms.
• History of trauma or family history of intergenerational trauma.
• Family history of medical issues, mental illness, and addiction.
• The client's medical history can include but is not limited to allergies, surgeries, head injuries, pregnancies and postpartum complications, thyroid issues, and hospitalizations.
• The client’s living situation, including who they live with, the number of dependents they care for, socioeconomic status, and any relevant information about how the client’s neighborhood impacts the client’s mental health.
• Difficulties within a client's occupation. For a child, this would mean looking at their school involvement. For an adult, this considers the client's job, work environment, financial stressors, or difficulty finding a job.

Precipitating Factors  - This includes the events that have led to the client's presenting problem. Examples of precipitating factors include the loss of a job, the death of a loved one, or a car accident.

It is important to note there is no time limit on what qualifies as a precipitating factor. It is common for trauma survivors to seek psychotherapy for years, sometimes even decades, after the traumatic event. In these cases, it is advisable to document the history of trauma and any recent related occurrence that led to the client seeking treatment.

Perpetuating Factors  - These are ongoing stressors in the client's life that continuously contribute to the presenting problem. This could include addiction, abusive relationships, or caretaking for a loved one with extensive medical needs.

Thoroughly assessing and documenting perpetuating factors can help a clinician provide referrals to outside resources that would support the treatment and benefit the client.

Protective Factors  - Biopsychosocial assessments don't capture only the pathology and problems of a person's life. They also provide space to focus on strengths. Protective factors are the positive forces in a client's life that help moderate the presenting problem's impact or help prevent further decompensation. This might include a supportive family, a robust social network, hobbies, or a long history of success at school or work.

When the 5 P's are completed, a biopsychosocial assessment moves on to the final touches. This includes the Mental Status Exam and attaching any relevant psychological testing or outcome measures that were given. Finally, a summary, which consists of the most pertinent information from the 5 P's, is written. This summary should include details regarding safety risks and the report or observation of symptoms that would show the client meets the criteria for the diagnosis given. A diagnosis is documented, and treatment recommendations are laid out to cap off the BPS assessment.

How to format a Biopsychosocial Assessment?

There are a few formats a therapist can use for a biopsychosocial assessment. First, some organizations provide therapists with a BPS assessment form, where the clinician can fill in the blanks with thorough information. This approach creates uniformity for therapists working across the same organization. It also ensures that each area on the assessment form gets addressed, limiting the organization's liability.

Many clinicians in private practice take an approach to writing BPS assessments that more closely resembles writing a narrative. If you are a clinician taking this approach, consider using the following format from this biopsychosocial assessment example while incorporating information from the 5 Ps.

Biopsychosocial Assessment Example

Date: May 16, 2023

Client Name: Jane Nguyen

Referral Source: General Physician

DOB: April 18, 1982

• Demographics: Client is a 41-year-old Vietnamese American, married, cisgender, heterosexual female currently living with her husband of 6 years. She has three children, a son (age 6) and two daughters (age 16 and 12), who live in the home. Client reports she is employed full-time as a nonprofit attorney. Client reported she has lived in the U.S. since the age of 3, when she came to the U.S. as a refugee.
• Presenting Problem and History of Symptoms : The client reported seeking psychotherapy due to high levels of anxiety following a recent car accident. The client reported poor sleep, including nightmares and waking in the middle of the night. Stated she gets approx. 3-4 hours of interrupted sleep per night, and usually takes a sleep supplement to help her fall asleep. Client reported additional symptoms, including intrusive negative thoughts of the car accident, intense fears of another accident happening, negative self-talk, feelings of guilt, and passive suicidal ideation, including thoughts that others would be better off without her. Client reported her husband provided transportation to the assessment session and she has avoided driving since the accident occurred approximately 2 months ago. Client reported these symptoms were not present prior to the car accident although she has always had some difficulty with sleep. Client reported no alcohol or drug use.
• History of Mental Illness and Previous Mental Health Treatment: The client reported no previous history of mental health treatment. She stated she experienced low moods in her adolescence, which included a few instances of cutting behaviors to alleviate the pain she felt. The client reported no one ever knew about her cutting. The client denied history of suicide attempts. The client reported she knows she experienced some level of trauma when she was a child and her family came to the US as refugees but has no working memory of these experiences. The client reported some insight into her experience of intergenerational trauma in her family.
• Medical and Physical Health History : The client reported a history of fibroids, for which she had surgery in the past year. The client reported no other major medical issues or history of surgery. The client stated following the car accident, she received medical attention, and no long-term physical health effects were discovered.
• Family History : The client reported her husband has a history of alcohol abuse and noted he has been sober and active in AA for ten years. The client reported most likely her mother and father both suffered from trauma and depression, although it was never diagnosed or treated. She reported her mother would stay in bed for days on end, and she was often tended to by her oldest sister. The client reported cultural stigma around discussing mental health issues within her family of origin, and these concerns were never addressed openly.
• Social History: The client reported she was born into an intact family in Vietnam, and her family came to the US when she was three years old. The client reported her father worked in retail, and her mother was employed at the USPS. She stated she has two older sisters and an older brother, all of whom remain close.

The client stated she did well in college and law school and finds her work fulfilling. She reported she met her husband at a networking event for work and they dated for 10 years before getting married and having children.

She reported close relationships with friends, many of whom have children the same age as her, although has not been motivated to go out socializing since the car accident occurred.*

• Risk Assessment: The client reports passive suicidal ideation and currently contracts for safety. She denied having a plan or intent to self-harm. Stated she would never harm herself as she could not do that to her children.
• Client Strengths and Protective Factors : The client is an astute, intelligent, gainfully employed woman. She reported having a strong support system, including close relationships with her husband, friends, extended family, and her children. The client reported hobbies, including hiking, yoga, and painting.
• Summary The client is a 41-year-old Vietnamese American, married, cisgender, heterosexual female currently living with her husband of 6 years and their children. The client reported current symptoms following being in a traumatic car accident approx. 2 months ago, including difficulty sleeping, intrusive negative thoughts, negative self-talk, feelings of worthlessness and guilt, avoidance of trauma reminders, social isolation, anhedonia, and passive suicidal ideation. The client reported a history of untreated mental health symptoms in adolescence, including depressed mood and cutting behaviors, as well as a history of trauma from childhood, many of which are pre-memory. Discussed also a family history of generational trauma and depressive symptoms with no history of formal diagnosis or treatment. Client denies current intent or plan to self-harm. Expressed a sense of hope for the future.

Client’s symptoms and score on the PCL5 (43) are consistent with a diagnosis of Post-Traumatic Stress Disorder.*

• Diagnosis F43.10 Post-Traumatic Stress Disorder
• Treatment Recommendations and Referrals Recommended to attend EMDR psychotherapy 1x/week. Recommended to seek support from G.P. around her use of sleep aid.

Increase your practice's revenue and reduce therapist burnout

As you may have guessed by now, writing a thorough biopsychosocial assessment has historically been incredibly time-consuming. Gathering the relevant information through client meetings typically takes 1-2 hours, depending on the severity of the client's symptoms and the intensity of their experience. Meeting with collateral contacts, such as parents, teachers, and psychiatrists, can add another 1-3 hours. This doesn't even include writing the assessment! Writing the biopsychosocial assessment can add another 2-3 hours, not including the time it takes to work up the courage to open the laptop to write! The entire biopsychosocial assessment writing process done the old-fashioned way can take 3-8 hours (not including time spent procrastinating). Most therapists don't have time in their schedules for these unpaid hours of clinical documentation.

This is where AI technology comes in.

Mentalyc is an affordable,  HIPAA-compliant  psychotherapy note software that uses Artificial Intelligence to save therapists time. Mentalyc's easy-to-use platform listens in on client and collateral sessions, identifies relevant information, and uses this info to create a well-written biopsychosocial assessment quickly. Therapists can then review the document, make any changes, and finalize the assessment by signing and dating it. As a result, writing the BPS assessment takes a fraction of the time it used to, while the end product remains thorough and well-written. If you’re ready to save time on BPS assessment writing, register for Mentalyc .

When writing a BSP assessment, there are a few tips to keep in mind to ensure that it is clear, objective, and effective:

• Write in the 3rd person.
• Document everything you ask about, even if the client denies it is an issue for them. If you don't document a client response, it looks like you didn't ask.
• Stay away from jargon or technical terms.
• Use clear, concise language.
• There is no one way to ask biopsychosocial assessment questions; however, therapists should pay attention to detail with follow-up questions. These include asking about symptoms' intensity, frequency, and onset or clarifying the timeline of reported experiences.
• Biopsychosocial assessment tools can include outcome measures, which are often found in the public domain for free. These tools, such as the  PHQ-9 or  GAD-7 , help a therapist gain more information regarding the client’s experience of symptoms but cannot be used by themselves to make a diagnosis.
• Biopsychosocial assessments are used widely in the fields of social work and psychotherapy. Here is a biopsychosocial in social work  example .
• To understand the client holistically, it is essential to consider their race, ethnicity, and culture in each portion of the biopsychosocial assessment.
• The assessment information should be consistent. For example, it is problematic if the last page of an evaluation includes a Substance Use Disorder diagnosis and there is no mention of the client's drinking or drug patterns anywhere on the previous pages.
• After completing the biopsychosocial assessment, a corresponding progress note should also be created for the client’s chart. In simplest terms, the progress note documents the writer’s intervention and key components of the client’s report. The assessment lays out the client’s story and symptoms in detail.

One of the most important considerations when writing a BPS assessment is to stick to the facts. This includes documenting only what behaviors you have observed or what has been reported. A therapist's opinions and value judgments do not belong in clinical documentation. AI software, such as  Mentalyc , helps ensure the tone of documents is written objectively.

In conclusion, writing an effective biopsychosocial assessment is a critical component in diagnosing and treating mental health issues. Using the 5 Ps for case formulation helps us better understand our clients and the essential factors we must consider as we begin treatment. By following these guidelines and using HIPAA-compliant software like Mentalyc, mental health professionals can ensure that their biopsychosocial assessments are informative and objective.

• Macneil, C. A., Hasty, M. K., Conus, P., & Berk, M. (2012). Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice. BMC Medicine, 10(111), 1–3. https://doi.org/10.1186/1741-7015-10-111

About the author

Ann Dypiangco

Ann Dypiangco, LCSW is a mental health therapist and tech enthusiast who specializes in perinatal mental health and trauma. With a master's degree from Boston College, Ann has extensive training in psycho-sensory techniques such as EMDR and Havening. She is licensed in California and runs a small virtual practice. Ann is passionate about the intersection of technology and mental health and is excited about how AI and the metaverse will transform the industry.

Learn More About Ann

All examples of mental health documentation are fictional and for informational purposes

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Analysis of Real-World Implementation of the Biopsychosocial Approach to Healthcare: Evidence From a Combination of Qualitative and Quantitative Methods

Xiaohua xiao.

1 School of Public Health, The Children's Hospital, and National Clinical Research Center for Child Health, School of Medicine, Zhejiang University, Hangzhou, China

Haidong Song

2 Affiliated Mental Health Center Zhejiang University School of Medicine (Hangzhou Seventh People's Hospital), The 4th Clinical College of Zhejiang Chinese Medical University, Hangzhou, China

3 Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China

4 School of Public Health, Zhejiang University, Hangzhou, China

Associated Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Aims: The modern medical model has been transformed into a biopsychosocial model. The integration of the biopsychosocial approach in healthcare can help improve the effectiveness of diagnosis and treatment. This study explored the actual application of the biopsychosocial approach in healthcare and provides a basis for targeted interventions to promote the biopsychosocial approach in healthcare.

Methods: Study 1 involved one-on-one interviews with 30 medical staff and focus group interviews with 16 recent patients. Study 2 was a cross-sectional survey of 13,105 medical staff in Hangzhou, China that analyzed the status quo implementation of the biopsychosocial approach in healthcare.

Results: Study 1 found that medical staff did not welcome patients to report information unrelated to their disease, hoping patients did not express their emotions. In the treatment process, patients believed that medical staff refused to attend to or did not encourage reporting of any information other than the disease, and that patients should have reasonable expectations for medical staff. Study 2 found that medical staff had a 37.5% probability of actively paying attention to the patient's psychosocial status. Female medical staff (38.5%) were actively concerned about the patient's psychosocial status significantly more than male medical staff (34.2%) ( P < 0.01). The medical staff in the psychiatric department (58.4%) paid more active attention to the patient's psychosocial status than staff in the non-psychiatric departments (37.2%). Gender, department, hospital level, and professional title were the factors associated with the medical staff's attention to the patient's psychosocial status ( P < 0.05). The influence of age on the probability of medical staff actively paying attention to the psychosocial status of patients increased with the number of years of employment. Participants that were 31–40 years old, had an intermediate professional title, and 11–15 years of employment were the least likely to actively pay attention to patients' psychosocial status.

Conclusion: Although the biopsychosocial approach has been popularized for many years, it has not been widely used in medical care. Medical staff pay more attention to patients' physical symptoms and less attention to patients' psychosocial status. It is recommended that training will be provided to medical personnel on implementing a biopsychosocial approach with particular attention to the sociodemographic characteristics of medical personnel. Additionally, we propose helping patients set reasonable expectations, and formulating guidelines for implementing the biopsychosocial approach.

Introduction

With the changes in the spectrum of human diseases, understanding psychological disorders and symptoms continue to deepen. People have become increasingly aware that no single reason could cause the appearance of symptoms, and psychological and social factors need to be considered. Therefore, a purely biomedical model cannot serve and meet the needs of contemporary medical care. In 1977, Engel ( 1 ) pointed out the limitations of the biomedical model, integrated psychological and social dimensions, and proposed a biopsychosocial approach. Engel held the view that disease is the result of the interaction of biological, psychological, and social subsystems on multiple levels and highlighted the indispensable role of psychosocial factors, which explained such phenomena as the effect of living conditions on the development of the disease. The premise of the biopsychosocial approach is that the patient's disease cannot be divorced from his or her psychosocial causes, personality, and surroundings ( 2 ). Evidence has shown that social/environmental and psychological factors matter in the development of psychiatric disorders ( 3 ). In the following decades, the biopsychosocial approach was mentioned in many disciplines and practical fields, including medical traumatic stress, anorexia nervosa, addiction treatment, daily pain, elderly frailty, disability, and health psychology ( 4 – 10 ). With the recognition that some risk factors of the disease are psychosocial rather than biomedical, and that some non-pharmacologic and non-surgical treatment modalities have a therapeutic effect, the biopsychosocial approach potentially improves clinical outcomes for chronic diseases and functional illnesses seen in primary care ( 11 ). The biopsychosocial approach in healthcare can improve the effectiveness of diagnosis and treatment ( 12 ), which enhances patient satisfaction and can ease conflicts between doctors and patients.

In clinical training such as medical schools and graduate schools, the biopsychosocial approach has been widely taught to arouse attention to the interaction between various factors that affect health and cause diseases ( 13 ). However, integrating the biopsychosocial approach into healthcare practice has not been as successful as integrating the approach into research and medical education ( 14 ). Most modern healthcare is still based on the biomedical model of disease, which can help identify and treat many diseases. However, it has difficulty recognizing the multi-factor and complexity of many (including non-organic) diseases. In addition, it is easy to ignore the psychosocial status of patients, which may trigger unnecessary disease behaviors in patients ( 15 ). Although the biomedical model promotes many healthcare innovations, a biomedical perspective alone cannot guarantee favorable results, nor can it explain the placebo effect and health gaps. It must also include psychological and social factors ( 10 ). Suls and Rothman ( 16 ) proposed that applying the biopsychosocial framework has not been fully utilized and should be considered in health psychology theories and clinical practice. Fava and Sonino ( 17 ) pointed out that although the biopsychosocial framework has been implemented for many years and the evidence base has grown over time, the implementation of this framework in healthcare has been slow. According to Adler ( 14 ), studies have found that many medical staff, such as the staff in pain clinics and on medical psychiatric wards, do not adhere to Engel's biopsychosocial approach. The application of the biopsychosocial approach needs thorough evaluation of the psychological, behavioral, sociocultural, and spiritual dimensions of patients' problems, which is time-consuming ( 18 ). For physicians who are already overburdened with clinical, administrative, and possibly research tasks, it is a formidable task ( 11 ).

However, as diseases become more complicated and multi-factorial, studying the status quo implementation of the biopsychosocial approach has far-reaching significance in health care. Surprisingly, we know very little about the practical application of the biopsychosocial approach in healthcare. To fill this gap in the literature, we explored the practical application of the biopsychosocial approach in healthcare through qualitative and quantitative research methods. Qualitative research in this area can provide us with valuable and comprehensive information and deepen our understanding of the practical application of the biopsychosocial approach in healthcare. Carrying out large-scale quantitative research complements the qualitative data, by investigating and analyzing the current status of implementing the biopsychosocial approach in healthcare and related factors. The knowledge gained would provide a scientific basis for how to carry out effective interventions to promote the status quo implementation of the biopsychosocial approach in healthcare. Specifically, the study could serve as a reference and provide direction for promoting doctor-patient communication; improving patient participation, acceptance, and compliance; improving the effectiveness of diagnosis and treatment; and promoting the harmony in the doctor-patient relationship.

The primary purpose of this study was to explore the implementation of biopsychosocial approach in healthcare and any differences associated with the psychosocial status of patients with different sociodemographic variables. One important factor is the gender of the medical professional. During the consultation process, female doctors have been shown to provide a longer consultation time than male doctors ( 19 ). In addition, women were found to use more emotion-focused coping strategies than men ( 20 ). Therefore, female doctors may pay more attention to patients' emotions and social factors. Thus, we examined the following hypothesis.

• H1: Female medical staff pay more attention to the psychosocial status of patients than male medical staff.

The organizations in which people work affect their thoughts, feelings, and actions in the workplace ( 21 ). Hence, the difference in working environments may affect the thoughts and behaviors of medical staff. In a psychiatric department, because the working environment involves patients with mental illness, psychiatric staff may pay more attention to the psychosocial status of patients than in an environment where the medical staff are working with non-psychiatric patients. Therefore, we examined the following hypothesis.

• H2: Psychiatric medical staff pay more attention to the psychosocial status of patients than non-psychiatric medical staff.

In China, hospitals are divided into three levels according to their functions and tasks ( 22 ). The first-level hospitals provide the community with primary healthcare, prevention, rehabilitation, and health care services. The second-level hospital is responsible for providing diagnosis and treatment of common and frequently occurring diseases for the community. The tertiary hospital is a comprehensive medical institution that provides specialized medical services ( 23 ). Medical staff at different hospital levels face different workloads, different kinds or parts of training, and different working environments, which may affect their attention to the psychosocial status of patients. Among them, tertiary hospitals provide diagnosis and treatment services for acute, critical, and difficult and complex diseases, which require comprehensive evaluation of patients. As such, medical staff in tertiary hospitals may pay more attention to the psychosocial status of patients than medical staff in secondary hospitals and first-level hospitals. Consequently, we proposed the following hypothesis.

• H3: Medical staff in tertiary hospitals pay more attention to the psychosocial status of patients than medical staff in first- and second-level hospitals.

Lastly, it has been shown that burnout symptoms among doctors are prevalent and associated with age, professional title, and long working hours ( 24 ). Age and years of employment are related to the psychosocial workload of medical staff ( 25 ), which may affect the attention of medical staff to the psychosocial status of patients. Medical staff may face pressure from job tasks and their promotion to professional titles, and the professional title may affect their attention to the psychosocial status of patients. Medical staff with senior professional titles may pay more attention to the psychosocial status of patients. However, medical staff with junior and intermediate titles are faced with heavy workloads and the pressure to be promoted. Therefore, they may pay less attention to the psychosocial aspects of patients. Given these differences, our last hypothesis was as follows:

• H4: Medical staff's attention to patients' psychosocial status will be associated with their age, years of employment, and professional title.

Materials and Methods

Design and participants.

This research study used a combination of qualitative and quantitative research methods. Study 1 conducted one-on-one interviews with 30 medical staff and conducted focus group interviews with 16 recent patients to summarize the views of both doctors and patients on the biopsychosocial approach. Participants in the one-on-one interviews were selected through random sampling from medical staff in the outpatient and ward areas of a large tertiary hospital in Zhejiang, China in September 2019. The researcher introduced himself to the interviewees who met the inclusion criteria and explained the purpose and methods of the study. After obtaining consent, the interview was conducted according to a semi-structured interview outline determined in advance. The interview began by asking for basic information on the participant, such as department and years of employment, which was followed by the interview questions, such as “What information do you want the patient to tell you when you are providing treatment?” and “What about the patient's behavior do you think will hinder the diagnosis and treatment?” The participants included 13 men and 17 women. Their average working experience was 9.84 ± 8.08 years and they were from diverse medical fields (e.g., internal medicine, urology, endocrinology).

Two focus group interviews were conducted in June 2020, and each group included eight participants. A semi-structured interview outline was prepared in advance for the purposes of the group interview, which asked the participants to “Please talk about your most recent medical experience,” and questions such as “During the treatment, what behaviors or reactions do you think will promote or hinder the medical treatment process?” Inclusion criteria for the focus group were clear verbal expression and medical experience in the past 6 months. The participants were 6 men and 10 women with an average age of 22.9 ± 2.11 years. The researcher introduced himself to the patients who met the inclusion criteria and explained the purpose and methods of the research. The researcher obtained informed consent from each participant before conducting the focus group. Focus group interviews were recorded and the researcher took notes.

From December 2020 to January 2021, Study 2 was carried out in Hangzhou, Zhejiang Province. An anonymous online questionnaire was used to gather data on the current status of implementing the biopsychosocial approach in healthcare. The questionnaire asked for demographic information including gender, department, hospital level, professional title, age, years of employment, and the probability of actively paying attention to the patients' psychosocial status. To assess the probability of medical staff actively paying attention to the patient's psychosocial status, participants were asked, “During the consultation process, in ()% of the cases, I will actively pay attention to the patient's psychosocial status rather than just the physical symptoms.” A total of 13,105 medical staff were surveyed.

Table 1 shows detailed information on the participants' characteristics. Of the 13,105 eligible medical staff that were included in this study, 23.5% ( n = 3,084) were men and 76.5% ( n = 10,021) were women. A total of 1.6% ( n = 206) were psychiatric medical staff and 98.4% ( n =12,899) were non-psychiatric. There were 2,681 (20.5%) medical staff from tertiary hospitals, 5,064 (38.6%) medical staff from second-level hospitals, and 5,360 (40.9%) medical staff from first-level hospitals. Approximately half (50.8%) of the medical staff had junior titles and 4,627 (35.3%) had intermediate titles. In terms of age, 27.6% ( n = 3,614) were ages 20–30, 41.7% ( n = 5,466) were 31–40, 20.3% ( n = 3,018) were 41–50, and 7.7% ( n = 1,007) were ages 51 or older. With regard to years of employment, 19.6% ( n = 2,567) were employed 0–5 years, 19.9% ( n = 2,603) 6–10 years, 25.2% ( n = 3,305) 11–15 years, 9.8% ( n = 1,289) 16–20 years, and 25.5% ( n = 3,341) were employed for 21 years or more.

The descriptive characteristics of the participants.

The M and SD in this table are the mean and its associated standard deviation of the probability of medical staff actively paying attention to the patient's psycho-social state .

Statistical Analyses

In Study 1, we used thematic analysis to analyze the qualitative data. Initially, we transcribed the recorded interview then reviewed the transcribed data three times to obtain a general understanding. Next, we extracted semantic units and classified them as compact units. We then honed the important parts of each unit and what aspects of the qualitative data it covered. Next, the compact unit was further summarized and marked with appropriate headings. In addition, we searched for overlapping areas between topics, identified emerging subtopics, provided more detailed topic descriptions and described the hierarchical structure in the data, and clearly defined the scope of each topic. Finally, the sub-categories were grouped according to similarities and differences, and appropriate titles that could represent the resulting categories were selected.

In Study 2, we analyzed the sociodemographic variables and calculated the number and percentage distribution of the categorical variables. The independent t -test and one-way analysis of variance were used to determine sociodemographic differences among medical staff with regard to actively paying attention to patients' psychosocial status. Lastly, all variables were included in a stepwise linear regression model (the entry/clearance criterion was P = 0.05/0.1) for analysis. All statistical analyses were performed using IBM SPSS Version 26.0, and P < 0.05 (two-tailed) was considered statistically significant.

Medical Staff Do Not Welcome Patients to Report Information That Is Not Related to the Disease

During the consultation process, some medical staff paid more attention to the patient's physical symptoms. Patients were not welcome to report information that was not related to the disease. Medical staff hoped that the patient would grasp the key points when explaining their condition.

“The patients only need to talk about the disease and what is related to the disease during the communication with medical staff, and not mention other content.” (A male orthopedic doctor who has worked for 10 years)

“During the treatment, the patient does not need to say too much that has nothing to do with the symptom.” (A female doctor in the urology department who has worked for 7 years)

“I hope that the patient's parents can accurately provide the child's medical history and clearly describe the condition.”(A female neonatologist who has worked for 7 years)

“The patient should focus on the critical points in the process of describing the condition.” (A female internal medicine outpatient doctor who has worked for 1 year)

Medical Staff Hope That Patients Will Not Confide in Them

The medical staff said that although they can understand the patients' mood, they hoped that the patient would not confide their emotions to them and that they need to a maintain a rational attitude.

“Although the patient's mood is understandable, the patient does not need to say many things that have nothing to do with the patient's condition and only need to answer my questions accurately.” (A respiratory physician who has worked for 9 years)

“I hope that the patients will not confide their emotions to the medical staff.” (A female doctor in the gastroenterology department who has worked for 3 years)

“The patient's anxiety is understandable, but the patient should maintain a rational attitude during the treatment process.” (A female doctor in the endocrinology department who has worked for 8 years)

The Patient Felt That Medical Staff Refused to Pay Attention to the Patient's Psychosocial Status

Some patients expressed their desire to get the attention of medical staff, thinking that the medical staff refused to pay attention to the patient's psychosocial status, which made patients feel dissatisfied.

“I want to describe my symptoms perfectly to the medical staff, but the medical staff seems to know me well, and the medical staff do not let me say too much. I feel a little dissatisfied. I want to talk to the medical staff, but the medical staff refuse to understand me.” (Patient Y, male)

“The patients are eager to get the kind of attention from the medical staff. But if there is no particular situation, the medical staff will not pay attention to the patient deliberately.” (Patient Z, female)

“I feel obstructed when communicating with some doctors, and the doctors may not listen carefully to what I say.” (Patient C, female)

Patients Should Have Reasonable Expectations for Medical Staff

Most doctors believed that patients' high expectations would impact the effectiveness of diagnosis and treatment, so patients should have reasonable expectations. Some patients held the view that the patient's expectations for medical staff should be reasonable.

“Excessive expectations of patients have an impact on the effectiveness of diagnosis and treatment. I hope patients have reasonable expectations.” (A male dentist who has worked for 7 years)

“Medical staff have as part of their responsibilities to take care of patients' emotions, but do not expect clinical medical staff to comfort patients like psychological medical staff.” (Patient A, female)

“Patients are emotionally sensitive, which may hinder the doctor's diagnosis and treatment. Sometimes patients need to control their emotions and calm their minds to some extent.” (Patient D, female)

Comparison of the Probability of Medical Staff Actively Paying Attention to the Psychosocial Status of Patients

There were significant differences in the probability of actively paying attention to the psychosocial status of patients according to gender, department, hospital level, professional title, age, and years of employment ( P < 0.01). Female medical staff (38.5%) were more likely to pay attention to the psychosocial status of patients than male medical staff (34.2%) ( P < 0.01). The medical staff in the psychiatry department (58.4%) paid more attention to patients' psychosocial status than the medical staff in other departments (37.2%).

Table 2 provides the results of the comparisons according to hospital level, professional title, age, and years of employment. The probability of medical staff in second-level and tertiary hospitals actively paying attention to the psychosocial status of patients was significantly higher than that of medical staff in first-level hospitals, and medical staff in tertiary hospitals were more likely to pay attention to psychosocial status than medical staff in second-level hospitals.

Comparison of medical staff in different demographic characteristics actively paying attention to the psycho-social state of patients.

The CI means a 95% probability that the confidence interval contains the overall mean. The probability of correct estimation is 0.95, and the probability of estimation error is 0.05 .

The probability of medical staff 20–30 years old actively paying attention to the patient's psychosocial status was significantly higher than that of medical staff 31–40 years old and those who were 41–50 years old. Medical staff aged 41–50 and over 50 were more likely to pay attention to the psychosocial status of patients than those who were 31–40. The medical staff over the age of 50 were more likely to actively pay attention to the psychosocial status of patients than those aged 41–50. Medical staff aged 31–40 were the least likely to pay attention to patients' psychosocial status.

The probability of medical staff with junior professional titles actively paying attention to the psychosocial status of patients was significantly higher than that of the medical staff with intermediate professional titles and deputy senior professional titles. The probability that medical staff with deputy senior professional titles and senior professional titles actively pay attention to the psychosocial status of patients was significantly higher than that of the medical staff with intermediate professional titles. Medical staff with intermediate professional titles were the least likely to pay attention to the psychosocial status of patients.

Medical staff who had worked for 0–5 years were more likely to actively pay attention to the psychosocial status of patients than other medical staff who had worked for more years. Medical staff who had worked for 6–10 years were more likely to pay attention to the psychosocial status of patients than those who had worked for 11–15 years. Medical staff who had worked for more than 21 years were more likely to pay attention to the psychosocial status of patients than those who had worked for 11–15 years. Medical staff who had worked for 11–15 years were the least likely to actively pay attention to the psychosocial status of patients.

Regression Analysis on the Probability of Medical Staff Actively Paying Attention to the Psychosocial Status of Patients

In order to identify the statistical significant characteristics of medical staff who actively pay attention to the psychosocial status of patients, we first included all sociodemographic variables into the stepwise linear regression analysis. Gender was indexed as 0 = male, 1 = female. Then, considering the possible interaction between hospital level and professional title, and between age and years of employment, we included the interaction terms “hospital level × professional title” and “age × years of employment” into the regression equation. The results are shown in Table 3 . Gender [β = 0.05, CI (2.66, 5.19), P < 0.01], department [β = 0.07, CI (13.48, 21.93), P < 0.01], hospital level [β = 0.10, CI (3.51, 4.92), P < 0.01], and professional title [β = −0.04, CI (−2.41, −0.68), P < 0.01] were statistical significant predictors of the probability of medical staff actively paying attention to the psychosocial status of patients. Age and years of employment were not statistical significant. Age and working years cannot independently predict the probability of medical staff actively paying attention to the psychosocial state of patients. But the interaction of age and years of employment was statistical significant [β = 0.11, CI (0.03, 0.04), P < 0.01]. The influence of age on the probability of medical staff actively paying attention to the psychosocial status of patients increased with the increase in years of employment. The interaction of hospital level and professional title level was not statistical significant.

Linear regression analysis of the probability of medical staff actively paying attention to the psycho-social state of patients.

The β is the estimate resulting from an analysis performed on standardized variables, representing the effect of an independent variable on the dependent variable. The SE indicates the deviation between the actual value and the regression estimate due to sampling error. The t is the significance test value of the t-test of the regression coefficient. The CI means a 95% probability that the confidence interval contains the overall mean. The probability of correct estimation is 0.95, and the probability of estimation error is 0.05 .

In this study, we explored the implementation of the biopsychosocial approach in healthcare through a combination of qualitative and quantitative research methods. Our focus was to understand the experience of medical staff and patients with regard to the attention given to the psychosocial status of patients, and determine what sociodemographic factors were associated with differences among medical staff in the active attention they give to patients' psychosocial status. One qualitative research finding was that medical staff do not welcome patients to report information unrelated to the disease and hope that patients will not confide in them. Quantitative research found that medical staff had a 37.5% probability of actively paying attention to the patient's psychosocial status. This shows that medical staff focus on the patient's physical symptoms and tend to ignore the patient's psychosocial status. Based on the sample in the present study, it can be concluded that the biopsychosocial approach is not sufficiently applied in healthcare.

Another finding from the qualitative study was that some patients held the view that medical staff refused to pay attention to the patients' psychosocial status. The patients were eager to get such attention from the medical staff, which is consistent with previous research results. Vinson found that patients increasingly wanted to interact emotionally with medical staff ( 26 ). In the eyes of patients, the medical staff take care of the patient's emotions to a certain extent, which helps patients to relax. Patients feel helpless and hopeless in the face of the disease, and medical staff play an essential role in providing support to patients ( 27 ). The integration of biopsychosocial methods in healthcare needs to be established within medical staff ( 14 ).

In addition, according to the results of the qualitative study, patients should have reasonable expectations of the medical staff. Patients who go to the hospital generally have expectations regarding the care that they will receive. These expectations range from a desire for information or psychosocial support to expectations for specific tests or treatments. Fulfillment of patients' expectations may influence health care utilization, affect patient satisfaction, and be used to indicate quality of care ( 28 ). Health care expectations may be positive or negative ( 29 ). Particular emphasis should be placed on patients with excessive expectations, as the lack of an achievable balance between expectations and fulfillment may lead to dissatisfaction ( 30 ). Therefore, in routine medical services, medical staff should discuss the treatment plan with patients and the realization of short- and long-term goals to ensure that patients' expectations are realistic and reasonable ( 31 ). Medical staff should actively listen to determine patients' understanding and concerns about the disease, respond to patients' concerns, and help set reasonable expectations, which is helpful to establish a harmonious doctor-patient relationship.

The quantitative study results verified our first hypothesis. Female medical staff (38.5%) were more likely to actively pay attention to the psychosocial status of patients than male medical staff (34.2%). Our findings are consistent with prior studies indicating that the gender of the doctor is a relevant factor in the differences in medical care provided. For example, it was found that female doctors take an average of 2 min longer to see a patient than male doctors ( 32 ), are more likely to ask patients about health risks and unhealthy behaviors and provide more psychological support ( 33 ).

In addition, department and hospital level were factors associated with medical staff actively paying attention to the psychosocial status of patients. Psychiatric medical staff actively paid more attention to the psychosocial status of patients than non-psychiatric medical staff. This verifies our hypothesis that psychiatrists would pay more attention to the psychosocial status of patients due to the particularity of the department. However, our results showed that only 58.4% of the psychiatric medical staff paid attention to the patient's psychosocial status. Regarding hospital level, medical staff in tertiary and second-level hospitals were more likely to actively pay attention to the psychosocial status than medical staff in first-level hospitals. To a certain extent, our results are consistent with Meretoja et al.'s ( 34 ) finding that competence profiles differed in both the level and infrequency of using competencies according to work environment. There are differences in the work environments of hospitals of different levels, including the competence of the medical staff, which may affect the degree to which medical staff pay attention to the psychosocial status of patients.

The hypothesis that medical staff's active attention to patients' psychosocial status is related to age, years of employment, and professional title was also supported. Professional title and the interaction of age and years of employment had predictive effects on the probability of medical staff actively paying attention to the patient's psychosocial status. The influence of age increased with the increase in years of employment. We found that the medical staff aged 31–40 years, with an intermediate professional title, and 11–15 years of employment were least likely to actively pay attention to the patient's psychosocial status. Previous studies have found that age, working years, and work burden were essential predictors of job burnout for doctors and nurses ( 35 ). Compared with other occupations, occupational stress and burnout symptoms were more common among doctors ( 36 ). The job burnout of doctors was related to changes in the professional environment, such as financial pressure, increased workload, and index assessment ( 37 ). Therefore, we speculate that medical staff aged 31–40 with intermediate professional titles and 11–15 years of employment may have a heavier workload, more tremendous pressure for promotion, and face more severe job burnout. Thus, they have the lowest probability of actively focusing on the patient's psychosocial status.

Based on the findings mentioned above in this study, the biopsychosocial approach has not been widely used in healthcare. Most medical staff tend to only focus on the patients' physical symptoms and not pay attention to the patients' psychosocial status. Hence, it is recommended that the biopsychosocial approach be promoted in medical treatment through training and interventions for medical staff, primarily geared to those with the lowest probability of actively focusing on the patients' psychosocial status. Further, it is suggested to comprehensively popularize the knowledge of medical psychology among medical staff and carry out the research of disease psychology, which will help strengthen the medical staff's attention to the biopsychosocial medical model. Then, in medical practice, guidelines for implementing the biopsychosocial medical model should be formulated so that the patients' disease's biological, psychological, and social components are considered and managed as a whole. For example, medical and psychology departments could establish an efficient consultation, referral, or a multi-disciplinary treatment team to enhance patient diagnosis and treatment.

Strengths and Limitations

This research explored the integration of the biopsychosocial approach into health care from the perspective of medical staff and patients. Using qualitative and quantitative methods, the study provides comprehensive information and fills a gap in the research on the application of the biopsychosocial approach. The study included a diverse and extensive sample of medical staff, as well as interviewing doctors and patients for their perspective on the issue. Furthermore, the study investigated sociodemographic variables in relation to medical staff's attention to patients' psychosocial status. As such, the study provides scientific evidence for carrying out effective interventions to promote the implementation of the biopsychosocial approach in healthcare.

This study has some limitations. Firstly, although the sample included 13,105 medical staff in Hangzhou City, the results may not be generalizable to the situation of medical staff in other countries and regions. Future research should focus on other countries and regions with comparative analyses. Secondly, Study 2 used self-report questionnaires, which are subject to response bias such as social desirability. Lastly, this is a cross-sectional study which does not show how these variables behave over time. Future studies should consider using longitudinal designs.

Although the biopsychosocial approach has been popularized for many years, it has not been widely used in medical care. The results of the present study suggest that medical staff tend to focus their attention on the patients' physical symptoms and are less inclined to attend to patients' psychosocial status. Gender, department, hospital level, professional title and the interaction of age and years of employment can play a predictive role in the extent to which medical staff pay attention to patients' psychosocial status. Therefore, it is recommended that training and interventions be provided for medical staff on integrating the biopsychosocial approach into the provision of health care. In developing and implementing any in-service training for medical staff, it would be important to consider how the factors identified in this study may impact the ability and motivation of medical staff to attend to the psychosocial status of patients. Additionally, we propose guidelines be formulated for implementing the biopsychosocial approach, and helping patients set reasonable expectations regarding what the medical staff is able to do given their job responsibilities and the timeframe they have to provide diagnosis and treatment.

Data Availability Statement

Ethics statement.

The studies involving human participants were reviewed and approved by ethical review institutions of Zhejiang University and related hospitals. The participants provided their informed consent to participate in this study.

Author Contributions

QY, XX, and HS contributed to the conception of the study. HS, TS, and ZW collected the data. YX and XX carried out data cleaning. XX performed the data analyses and wrote the manuscript. QY and HS contributed to critically revising the manuscript for important content. All authors have read and agreed to the published version of the manuscript and contributed to the article and approved the submitted version.

This research was funded by National Natural Science Foundation of China (Grant Numbers 71974170), Leading Innovative and Entrepreneur Team Introduction Program of Zhejiang (Grant Numbers 2019R01007) and Public Projects of Science and Technology Department of Zhejiang Province (Grant Numbers LGF21H090006) to HS.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

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Collection: psyc 6104 - spring / summer 2024, a biopsychosocial approach to counselling.

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Black, D. W., & Grant, J. E. (2014). DSM-5® Guidebook : The Essential Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association Publishing.

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Biopsychology

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