Bio-psychosocial-Spiritual (BPSS) Assessment and Mental Status Exam (MSE)

[Episode 2] This is the second part of a two-part lecture on diagnosis and assessment. In the first episode I reviewed the history of the DSM and the multiaxial system. In this lecture, I discuss the Bio-psychosocial-spiritual (BPSS) assessment as the means for providing context for the client's presenting problems. I discuss the purpose of each of the four life domains and how the information is used in social work practice. Emphasis is placed on solution-focused approaches to assessment. I end with a brief description of traditional format for organizing observations about the client - the Mental Status Exam.


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Transcript

Now we're going to talk about the biopsychosocial spiritual assessment.  Obviously, there are four components to this assessment.  You look at the biology, the psychology, the sociocultural and the spiritual.  I'm going to refer to the biopsychosocial spiritual as the BPSS assessment.

Basically, it's a concise summary of client information.  BPSS differs from a diagnosis because it provides a brief historical background about the possible causes for whatever problem the client is presenting with as well as identifying some of the strengths and resources that the client brings to the table.  Although assessments tend to be problem-focused – this is our history, they should include client strengths, assets and things that could help treatment along as well as things that could be barriers to treatment.

So, again, the BPSS assessment, it provides a context, a historical context for whatever it is that the client is presenting with and this is different than a DSM diagnosis, which is simply a categorization of a cluster of symptoms and a level of impairment and perhaps acknowledgement of distress.  The biopsychosocial spiritual assessment ultimately you want to answer the question how do these four areas contribute to the client’s current functioning.

Biological

For bio, we're looking at your basic needs:  food, shelter, clothing, medical, health, physical capabilities in a physical environment.

Psychological

In psychological, we're looking at the individual’s history, personality styles, intelligent, mental abilities, self-concept and identity, even medication history, diagnosis history and treatment history.

Now, there's a cultural issue that we need to discuss here briefly for the psychological. When you're working with biracial or multiracial individuals and you're identifying how they identify themselves and how they have identified themselves, this can differ over time.

So, for example, if you're working with an individual who considers himself biracial, his mom was Latina and his father was African-American, it could be that in the beginning of his life he identified more closely with his Latina mom. Perhaps he spent more time with her.  Perhaps the neighborhood in which he grew up had a higher concentration of Latino families.  Perhaps even spoke some Spanish at home, but as he grew into adolescence and then adulthood he identified more with his African-American male father.  Of course, it could be reversed.  It could be any possible combination of shifts in identities, but this is very different than a monoracial individual for whom racial identity, ethnic identity has not necessarily been a central focus of their development. So that’s a cultural issue that needs to be taken into consideration during the biopsychosocial spiritual assessment.

Socio-cultural

Now, socio-cultural assessment, this is where you look at who are your client’s friends, families, what is their community like, what's their social environment, their political environment even their economic environment.  The use of genogram is really helpful in this one to provide a family systemic overview of relationships and perhaps types of issues that have existed generationally that might contribute to the client’s current situation.

You can ask about the socio-cultural context by using open-ended questions to begin with such as tell me who is your family and then as you go along in the interview, you would use closed-ended questions such as would you characterize your relationship with him as abusive.  One of the things that’s important to remember as you do a social history or establish the sociocultural context is that you need to be familiar with developmental theories about ages and stages, transitional processes, life domains, cultural expectations and the life course.

This is particularly important when working with kids as the developmental processes of a 5-year-old can differ greatly from those of a 9-year-old or even a 13-year-old.  One of the things that is important culturally to keep in mind in the sociocultural part of the assessment is to find out what groups are currently important and what groups have been important.

For example, social institutions, they help transmit systems of oppression.  So, for example: school. Even though it is a sociocultural institution that many of us think of in positive terms especially those of us in academia who have been fairly successful in schools it’s important to remember that our clients haven’t always had positive experiences especially when those institutions are perpetuating racism, discrimination, other types of isms prejudiced against one group over another. When we think about school, for example, it could be that a parent had a really bad experience in school.  Some of the Latino parents with which I worked in Austin, Texas, they describe being paddled by their teachers for speaking Spanish in classes.  So this obviously can create a really negative image of school as an institution.  It doesn’t mean that education as a concept is necessarily not supported by the family.  So when you're doing a sociocultural assessment, it's important to tease out these issues of culture such as attitudes towards education.

Also to remember that this idea of race, what is your race, that is socially constructed as well. Back at the turn of the century, Italians, Jews and Irish were not considered white and if you need to do more thinking about that, there are plenty of books that can illuminate that.  Andersen and Collins’ Race, class, and gender: An anthology is an excellent place to start looking at some of those issues.

Spiritual

The final area is the spiritual assessment.  This is really what we consider your sense of self, sense of meaning and purpose, what your value base is and what your religious life is.  Now, the spiritual assessment wasn’t officially included in the biopsychosocial assessment before the 2000s.  It's a relatively new area and so people are still trying to figure out exactly what the assessment looks like.

The most important thing is when you think about context is how does the client see their spiritual life, what do they understand to be their affiliation with religious organizations, what is the context for spirituality and religion in their life.  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.

That’s a concept that was proposed by Hawkins back in ’95 and I think it can be really useful as a way of connecting and establishing a real trusting therapeutic alliance with your client.  Graybeal, in an article that he wrote for Families in Society in 2001 about integrating strengths-based assessment with the traditional biopsychosocial assessment, he’s developed an acronym called ROPES that you can use to think about strengths in assessment and ROPES stands for Resources, Options, Possibilities, Exceptions and Solutions and I won't go into the details here, but you can look up his article in Families in Society.  It's 2001 and he does an excellent job of discussing this system and how it integrates with the traditional assessment.

Working with kids

Finally, I want to say something about working with kids.  The biopsychosocial spiritual assessment as we've been talking about it has assumed that you're speaking with an adult who can provide information about their own life.  Now, if you're working with a kid, the situation can be somewhat different.  Oftentimes, kids are not the ones who have instigated coming in.  They’ve been brought in.  They might not necessarily even see that there's a problem and particularly if they're young enough, they don’t understand that their life has a context.  It just is their life.

So in the first interview with the kid, it's important to think about them as being involuntary.  You want to ask yourself who thinks the child has a problem.  Why is this a problem now?  What is going on in the child’s life now?  This again can provide you context that the biopsychosocial spiritual assessment might provide with an adult, but these are questions that you would ask of the parents or the legal guardians or a case worker, whoever happens to be with the kid.

And when you're with the kid, it's important to ask the questions how can I be helpful to you, what brings you here, why do you think you're here.  This can provide information about what the kid knows about the situation so that you can determine what treatments you're using and who actually is the client.  Susan Lukas in her book Where To Start and What To Ask, which is an excellent book, she cautions clinicians who are working with kids to don’t focus on entertaining the child.  Remember that just because children can't express themselves in words, it doesn’t mean they won't understand you when you express yourself.

So, for example, even though a child might only know four words to express basic emotions happy, sad, mad and scared, it doesn’t mean that they won't understand you when you use words that provide a little bit more subtlety of expressions such as overjoyed or frustrated or anxious.  Another thing that Lukas reminds clinicians working with kids is that most children communicate through symbolic and metaphorical play and this could look like using play therapy.

Specific types of play therapy could be drawing and there are certain assessments like family tree person that you can do with the client to gather information about how they see their world, but also to think about working with a client less in terms in terms of a conversation that you might have with an adult which might start out with so tell me why you're here, what would you like to work on.

These sorts of conversations aren't necessarily going to be effective with kids for whom communication is more metaphorical and is often done through play.  And finally, when you're interviewing a kid for the first time, it's important to understand what the role of the parent is both for the kid and for the parent.  For example, if the kid is an older child, 10, 11, 12, they might be concerned about the parent knowing what's being talked about in the session and the parent might be expecting to know exactly what's being talked about in the session.

What's true is that although parents have the legal right to documentation and a chart, it's not necessarily the case that you need to disclose exactly what happens in a session to a parent.  You can simply report on how the child is doing vis- a-vis their goals for treatment and that’s a sufficient and a reasonable way to both maintain confidentiality, establish rapport with the kid and also to make sure that you're setting firm boundaries between your work with the child and your work with the parent.

Mental Status Exam (MSE)

Now, the last type of assessment that one does in the typical assessment phase of working with someone is the mental status exam.  So if we think about a timeline, you have your biopsychosocial spiritual that could start as far back as grandparents or great grandparents leads all the way up until today.  Slight overlap would include symptoms and impairment and issues that are related to diagnosis, right.  And the diagnosis of course provides a snapshot of the client’s current functioning.

And then the final part of this timeline is in the session right then how do you see the client?  What do you observe about the client?  Whereas diagnosis and the BPSS have all been based on the facts, the data that you gather from your client and of course some of that data might need to be corroborated with other pieces of data such as school reports or court records or other people in the client’s family or social environment providing, corroborating information.  All of those facts make up your assessment.

The mental status exam, they're your observations and they can be used to establish what your observations were of the client when you first meet them and then you can think about how that is changed over time.  What is changed?  When did it change?  Did it change for the better or for the worse?  The typical mental status exam covers appearance.  How does somebody look?  How do they behave?

Their speech, for example is it slurred or pressured.  Their emotions, this looks at mood and affect.  Mood would be how does the client feel most of the time and the affect is how is the client showing emotions.  If a client reports that they're sad most of the time, but they're smiling and they laugh a lot when they're in session with you and they report that they're sad then their affect would not be congruent with their mood.

Thought process and content is the next area.  How does the client think and what does the client think about?  You would want to do your screening for suicidal, homicidal ideation at this point of the mental status exam.  Sensory perceptions, these would be indications of illusions – delusions or hallucinations, so you would want to find out if your client is hearing things, seeing things or feeling things that other people don’t see, hear or feel.  This can include tactile auditory or visual hallucinations.

The last two parts of the mental status exam are mental capabilities. This is commonly referred to as oriented x3.

• Are they oriented towards time, place and person?  
• Do they know what time it is?  
• Do they know where they are?  
• Do they know who are they are?  

You can also do sort of simple tests of intelligence, concentration.  A classic concentration test would be serial 3s for kids or serial 7s for adults that might be counting backwards from 100 to 1 using 7s and if you're working with kids, you could do it counting backwards from 20 to 1 using 3s, so 17, 14, 11, those sorts of things. And then finally attitude. How does the client behave towards you?

Mental status exam is your observations and you can think about doing the mental status exam during your initial meeting with the client or it can last over a couple of sessions as you gather more information.

Putting it all together, you have your biopsychosocial spiritual, which provides the context.  Some of that information can be used to help with creating a diagnosis because you have some symptoms that need to be present over time in order for diagnosis to occur and also you want to get an idea of how their level of functioning has changed over time, which would indicate how much impairment they're currently experiencing versus how much they typically experience.

And then finally the mental status exam, which is simply an organized way of documenting what your observations of the client would be and then once you have that then you have to do your write up and you have to be able to interpret all the information that you have gathered into a final evaluation.  And this evaluation is where you pull the most important information together so you can work on your treatment planning and of course finally the interventions.

So that’s it for biopsychosocial spiritual DSM diagnosis and mental status exam.

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References

Andersen, M. L., & Hill Collins, P. (Eds.). (2016). Race, class, and gender: An anthology (Ninth edition). Boston, MA, USA: Cengage Learning.

Andrews, A. B. (2007). Social history assessment.Thousand Oaks, CA: Sage Publications

Congress, E. P. (2004). Cultural and ethical issues in working with culturally diverse patients and their families: The use of the Culturagram to promote cultural competent practice in health care settings. Social Work In Health Care, 39(3-4), 249-262.

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Graybeal, C. (2001). Strengths-based social work assessment: Transforming the dominant paradigm. Families in Society: The Journal of Contemporary Human Services, 82(3), 233-242.

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APA (6th ed) citation for this podcast:
Singer, J. B. (Producer). (2007, January 22). Bio-psychosocial-Spiritual (BPSS) assessment and Mental Status Exam (MSE) [Episode 2]. Social Work Podcast [Audio podcast]. Retrieved from http://socialworkpodcast.com/2007/02/bio-psychosocial-spiritual-bpss.html