Completing a Biopsychosocial Spiritual Assessment in Social Work Adapted from: Johnathan B. Singer, PhD, LCSW

Biopsychosocialspiritual (BPSS) Assessment and Mental Status Exam (MSE) Retrieved from: http://socialworkpodcast.blogspot.com/2007/02/bio-psychosocial-spiritual-bpss.html

To complete your Biopsychosocialspiritual assessment, include the following domains (note: the link above provides an overview of the BPSS, along with an audio-recorded podcast):

I. Biological & Issue Presentation (this is approximately 1 paragraph write up) a. Client’s name (pseudonym for this assignment) b. Client’s age c. Where/how client lives d. Client’s overall physical health (i.e. general good health, heart disease, diabetic, etc.) e. Client’s identified gender, race/ethnicity f. Brief, general description of client’s physical presentation (i.e., well kept, unkempt, speech,

mood, etc.). Note that this should be as objective as possible based on the context/society where the client primarily dwells

g. Any additional biological information that maybe important to be aware of to understand the case

h. Reason for client’s presentation for care/service/support

II. Psychological (this is approximately 1 – 2 paragraphs) a. Mental health diagnosis history (if diagnosis/es available) b. History of medications for diagnoses/mental health (if any); include any self-medication to

minimize psychological/mental health symptoms c. Orientation (is client oriented to, or aware of, who they are, where they are, the time, and what

is occurring). See this resource for more information: https://www.verywellhealth.com/what-is- orientation-and-how-is-it-affected-by-dementia-98571

d. Any history of mental health and/or social work-related support for mental or behavioral health care and outcome of care

e. Any additional psychological information that may be important to be aware of to understand the case

III. Socio-Cultural-Environmental (this write up could be from one paragraph up to 3) Think of an eco-map, specifically, consider all of the factors external to the client that impacts them from a strength, or resilience perspective, as well as those factors that put the client at risk for negative or poor outcomes. Some things to consider may be (note – these are NOT exhaustive; they are intended to be examples. It is important that you evaluate the socio-cultural- environmental factors impacting the client and identify those areas that are RISKS factors versus PROTECTIVE factors and why):

i. Family/friend support ii. Occupation (Working? Not working? Is work stressful? Etc.) iii. Educational background iv. Legal background/history

IV. Spiritual (this is approximately 1 paragraph)

The spiritual domain is often aligned with religion; however, spiritual is much bigger than someone’s religious identity. Spirituality for the BPSS assessment, as Dr. Singer notes, is “what we consider your sense of self, sense of meaning and purpose, what your value base is and what your religious life is”. He goes on to state “One way to think about a clinical use of this is if somebody talks about spirituality as being important, you can conceptualize therapy as change that occurs in a sacred space of healing.” When writing this section, consider:

i. Spiritual identity of the client (i.e. religious, non-religious, spiritually-associated label such as Wiccan, Catholic, Muslim, Jewish, Rastafari, etc.)

ii. The role of spirituality for the client/in the client’s life (including how the spirituality of others may impact the client)

V. Social Worker Impressions & Treatment Goals (this is approximately 1-2 paragraphs. Be sure to clearly bullet or number your goals!) Here, conclude your assessment with your objective summation of the client and presenting issue. Then, based on the assessment and impressions, identify 2-3 potential goals for treatment, and your plans to engage client in the treatment planning phase. Give rationale (evidence from the literature) that supports your engagement plan. Note that your goals and engagement plan should be realistic and inclusive of your overall awareness of the client.

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