Tuesday, September 9, 2014

Biopsychosocial History and Collateral Data

Biopsychosocial History and Collateral Data

The Biopsychosocial (BPS) History is a hallmark of social work, recognizing the link between physical health, physical functioning and the individual's social environment. A comprehensive BPS history can provide extensive information to inform where additional assessment is needed and where the focus of treatment is required. However, if the client is the only reporter, the information can be limited, incongruent or falsified. Collateral data can provide verification of accurate information, complete gaps in accurate reporting, provide areas for additional investigation or correct bad information.

The BPS goes beyond the mind/body connection in vogue for much of the 20th century in the United States and recognizes the link between the physical/body, mental/mind, and emotional/social/spiritual aspects of the individual. Without such inclusion, vital aspects of the client will be missed, leaving crucial diagnostic information out of the clinical picture. Unless assessment is complete, treatment will be incomplete. Even if a professional could adequately argue he can complete an accurate diagnostic assessment without all three components, arriving at the same DSM-IV diagnosis as a clinician who completes a BPS, the clinician who does not complete a BPS will not be informed enough to do a complete treatment plan and may miss vital contributing factors. How then can treatment be complete if factors that impact the problem are not identified?

The BPS will include cursory identifying information, presenting problem/issue, summary impression, goals, discharge/transition plan and a diagnostic impression. The bulk of the instrument consists of three sections: the biological/medical (including substance related issues, medical conditions, medications, disability restrictions), psychological (including symptom/problems, mental status, family history of psychiatric issues, risk assessment), and social (including spirituality, cultural issues, educational background, developmental history, legal history, marital/relationship status and history, employment history/aspirations and needs/abilities/preferences).

The biological section of the BPS assesses the client's medical history, developmental history, current medications, substance abuse history and family history of medical illnesses. The clinician is interested in exploring issues related to diabetes, thyroid disease, cancer, high blood pressure, cardiac history, chronic pain and other health issues because health issues can mask as mental health symptoms or exacerbate them. A referral should be made to address medical concerns that are not being treated. Clients who are on medications can have care coordinated with the treating provider, and more should be known about the medication, as side effects can also mask as or exacerbate psychiatric symptoms or illnesses. Collateral data is helpful when abuse of substances is suspected, such as abuse of pain medication, or with medical information because it is outside the scope of social work practice.

The psychological issues in the BPS assess the client's present psychiatric illness or symptoms, history of the current psychiatric illness or symptoms, past/current psychosocial stressors and mental status. Exploration of how the problem has been treated in the past, past/present psychiatric medications and the family history of psychiatric and substance-related issues is also included. Substance-related illnesses and issues with the client or family may be categorized in various ways within the BPS. Some forms link it with the medical portion of the report, while others the psychological, and still others the social, perhaps with legal issues. Theoretical orientation, program focus or other more practical issues may drive where this and other elements are placed. The importance of psychological issues is self-evident, driving diagnostic criteria and primary treatment focus. While self-report may be reliable, having an additional source of information is useful, such as a family member, spouse or friend, to provide an additional perspective on the symptoms presented. Clients may, for example, have issues of shame or distorted thinking that prevent them from sharing accurate details about symptoms.

The social aspects of the BPS focus on the client systems, both proximal and distal, unique client context and may identify strengths and/or resources available for treatment planning. Included in this portion of the BPS are components such as spirituality, cultural factors, sexual identity issues/concerns, personal history, family of origin history, support system, abuse history, education, legal history, marital/relationship, work history, and risk assessment (suicidality, homocidality, impulse control, risk history).

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