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Behavioral Health Assessment: A Practical Model

by William W. Deardorff, Ph.D, ABPP.

3 Credit Hours - $0
Last revised: 08/19/2021

Course content © Copyright 2021 - 2022 by William W. Deardorff, Ph.D, ABPP. All rights reserved.


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Course Outline


Learning Objectives

The Development of the Biopsychosocial Model




The Biopsychosocial Model in Mental Health Practice

A Model of Assessment

Patient Targets





Interaction among Patient Targets


Health Care System


Interaction among Patient and Environmental Targets

Methods and Pitfalls in Assessment

Archival Data

Clinical Interview





Psychophysiological Measures

Understanding the Patient: The Goal of Assessment




This course reviews the biopsychosocial model and presents a practical approach for using it in behavioral health.  The biopsychosocial approach is applicable to all health and mental health disciplines including psychology, social work, counseling, nursing, medicine, and others.  The course begins with a review of the history of the development of the biopsychosocial model from Hippocrates to Engel.  The course then presents a model for assessment including techniques and pitfalls.


This course is based on the following materials and two articles that can be reviewed as pdf documents.  These are as follows:


Shorter, E.  The history of the biopsychosocial approach in medicine: before and after Engel.

To view and/or download the article, click Here.


Kaplan, D.M. and Coogan, S.L. The next advancement in counseling: The bio-psycho-social model.

To view and/or download the article, click Here.



Learning Objectives



  • Discuss the development of the biopsychosocial model
  • List five goals of the biopsychosocial assessment
  • List the four patient targets
  • Explain the interaction among patient and environmental targets
  • Explain the pitfalls of three different assessment methods



The Development of the Biopsychosocial Model


The biopsychosocial model of illness and health, in its current form, was originally proposed by Engel (1977).  The biopsychosocial model proposes that health and illness are influenced not only by biomedical variables, but also cultural, social, and psychological considerations.  Although this concept seems commonplace today, it was somewhat revolutionary at a time when the biomedical model prevailed including “the notion of the body as a machine, of the disease as a consequence of the breakdown of the machine, and of the doctor’s task as repair of the machine” (Engel, 1977, p. 131).


To understand and effectively apply the biopsychosocial model, it is useful to first look at its underpinnings, including its developmental history.  This begins with Hippocrates in the 4th century (BCE), a resurrection of interest in the late 19th century, and Engel’s interest beginning in the mid-20th century leading to his 1977 paper. 




The origins of the basic tenets of the biopsychosocial model (before it was a “model”) can be traced at least to Hippocrates.   Hippocrates is credited with being the first physician to assert that diseases were caused naturally and not as a result of superstition


or imparted by the gods.  According to Hippocrates, disease was not the result of the ravages of an indwelling demon (as was a common belief among other practitioners), but rather, a condition of disharmony in a person's body: a battle between the disease and the self-healing tendency of the body. Going against the establishment, he separated the discipline of medicine from religion, believing that disease was not a punishment inflicted by the gods.  Rather he posited that disease is the product of environmental factors, diet, and living habits. Consistent with his beliefs, there is not a single mention of a mystical illness in the entirety of the Hippocratic Corpus.



Hippocrates believed that the sick body triggers natural forces to restore equilibrium and restore good health. Hippocrates founded his teachings on the firm belief that, while the cause of disease could be found either outside or inside the victim, "it is our natures that are the physicians of our diseases." Hippocrates proved to be an unparalleled diagnostician without the aid of any modern devices.  To achieve this diagnostic acumen, Hippocrates used his powers of observation and logical reasoning. Writing of epilepsy, which was then thought of as a sacred disease, he said, "it is no more sacred than any other disease, but has a natural cause and its supposed divine origin is due to man's inexperience." He had an uncanny ability to foretell the course of a malady, laying more stress on prognosis relative to diagnosis. Therefore, the emphasis of his treatment was on the patient. 


Implicit in his writings is the belief that both health and disease are under the control of natural laws and reflect the influence exerted by the environment and the person’s way of life. Hippocrates believed that health depended on a state of equilibrium among the various internal factors that govern the operations of the body and the mind. Disease was considered by Hippocrates to be an infringement upon natural laws. He often stated that the life and lifestyle of the patient were implicated in the disease process and that the cause is to be found in the combination of circumstances rather than in the simple direct effect of some external influence.  Hippocrates and his Hippocratic medicine were themed on ‘crisis’. The term crisis was a point of progression of an illness that either had the power to kill a person or a patient could recover from it naturally. The theory of crisis was the founding base for Hippocrates and his medicine. Hippocrates worked on being kind with his medicine while treating a patient. The main foundation stone of Hippocratic medicine was its humble and passive nature.

Hippocrates is credited with healing many, including the king of Macedonia whom he examined and helped to recover from tuberculosis (disease of the lungs). His commitment to healing was put to the test when he battled the plague (a bacteria-caused disease that spreads quickly and can cause death) for three years in Athens (430–427 BCE). It is also clear that the height of his career was during the Peloponnesian War (431–404 BCE). His teaching was as well-remembered as his healing. A symbol of the many students he encouraged is the "Tree of Hippocrates," which shows students sitting under a tree listening to him. The teacher and doctor role combined well in 400 BCE, when he founded a school of medicine in Cos.


Engel’s Immediate Predecessors


As discussed by Shorter, many of the insights of Hippocrates became more relevant in the late nineteenth century, when physicians correctly began to realize there was little they could cure and thus sought psychological means of supporting their patients. Among the originators of the ‘patient-as-a-person’ movement was the Viennese internist Hermann


Nothnagel, who sought in the 1880s to resurrect Hippocratic holistic thinking and see the patient’s presentation of illness as the product of a range of circumstances, not just biology. As he said in his inaugural lecture in 1882, ‘I repeat once again, medicine is about treating sick people and not diseases.’



William Osler, the very icon of modern internal medicine, has been quoted as saying, ‘The good physician treats the disease but the great physician treats the patient who has the disease.’   As discussed by Shorter, these ideas continued through the 1920s and 1930s, in the form of such books as Harvard Professor of Medicine Francis Weld Peabody’s The Care of the Patient (1927) and Hopkins Internist George Canby Robinson’s The Patient as a Person (1939). As discussed by Shorter, “Although forgotten today, these specialists in internal medicine were once very much associated with the idea that the patient was more than ‘a sack of enzymes’, that personal history and social circumstances mattered as well, both in the pathogenesis of illness and in its treatment.”


Engel’s Biopsychosocial Model


The term ‘biopsychosocial model’ is associated with the name of George Engel, who was an internist, psychiatrist, and psychoanalyst. Long before his landmark article in Science in 1977, beginning in 1946, Engel was a vocal proponent of the nature of the mind–body nature of health and illness.  


Born in New York in 1913, Engel had graduated as a doctor of Medicine from Johns Hopkins University in 1938. Engel was introduced to psychoanalytic training at the New York Psychoanalytic Institute in 1949 and thus became an internist who was familiarized with American psychoanalysis.  Engel ended up at Rochester with a joint appointment in psychiatry and medicine until his retirement in 1983.  He helped make Rochester the pioneer center for cross-training medical undergraduates in the mind–body relationship. Engel’s background in medicine and psychoanalysis inclined him to search connections among somatic illness, personal development, and life situation. As can be seen, the concept of the biopsychosocial model began to take shape early in his work.


As discussed by Shorter, Engel incorporated his early model into all of his clinical research. For example, in 1956 he asked why patients with ulcerative colitis often seemed to develop headaches when the bowel illness was in remission.  His theory was that when headaches appeared in these patients, ‘there was evidence of strong conscious or unconscious aggressive or sadistic impulses’. When bleeding occurred, ‘the patient was feeling to varying degrees helpless, hopeless, or despairing’. The bottom line, not entirely convincing to all gastroenterologists, was ‘Bleeding ... characteristically occurs in the setting of a real, threatened, or fantasized loss, leading to psychic helplessness.’ Unlike many psychoanalysts of the time period, who considered psychological events to be primary, Engel believed that organicity itself could be primary with the psyche explaining the timing of the symptoms.  In Engel’s model, the mind and body interrelated, rather than the former dominating the latter. This distinction was crucial in later getting the biopsychosocial model adopted by non-psychiatrists.


During the 1960s, Engel’s clinical work began ever more to approximate his famous model, and moved away from the conventional psychoanalytic conceptualizations of the day (e.g. psychoanalytic theories of psychosomatic disorders, etc.).  Contrary to the standard psychoanalytic wisdom, Engel said there are “more complex psychosomatic inter-relationships, where the final organic process may be reached through a number of different sequences.”  A basic biopsychosocial model can be illustrated as follows:



Figure 1: Biopsychosocial Model


By the time he published his 1977 article in Science, Engel’s biopsychosocial model is essentially devoid of psychoanalytic concepts. Engel felt that not only psychiatry, but all of medicine, was in crisis as a result of applying the “biomedical model” where the biopsychosocial model should instead prevail.  The biomedical model meant the reduction of illness to measurable biological parameters and therapy (treatment) to an adjustment of these parameters leading to a cure.   The impact of Engel’s 1977 Science article was enormous. It placed the biopsychosocial model on the teaching and research agendas across almost all health and mental health disciplines.  


The Biopsychosocial Model in Mental Health Disciplines


Since the publication of Engel’s article, the biopsychosocial model has been adopted to a lesser or greater degree across virtually all areas of medical practice.  As discussed by Kaplan, although the teaching of the model in medical schools has been addressed, it has not been fully integrated into actual practice and the biomedical model still prevails.  The fields of psychology, counseling, and social work have also adopted the biopsychosocial model in both research and clinical practice.


One example of this adoption of the biopsychosocial model in psychology can be seen in the history of the field of clinical health psychology.  Matarrazo’s initial definition of health psychology (1980), followed by definitions of clinical health psychology (see Millon, 1982; See also, Belar, McIntyre and Matarazzo, 2003 for a history of health psychology), formed the foundation of a current definition (American Psychological Association; APA):



Current Definition of Clinical Health Psychology



Clinical health psychology applies scientific knowledge of the interrelationships among behavioral, emotional, cognitive, social and biological components in health and disease to the promotion and maintenance of health; the prevention, treatment and rehabilitation of illness and disability; and the improvement of the health care system. The distinct focus of Clinical Health Psychology is on the physical health problems.  The specialty is dedicated to the development of knowledge regarding the interface between behavior and health, and to the delivery of high quality services based on that knowledge to individuals, families and health care systems. (as cited in Belar and Deardorff, 2009, p. 5)



The reader may be wondering why the need for a biopsychosocial history lesson.  Having knowledge of these historical and definitional issues related to the biopsychosocial model is critical to understanding the fundamentals of assessment in this area.  As can be seen, if one has a good understanding of these concepts, the fundamentals of assessment become clear.  As can be derived from the various definitions (clinical health psychology and other), the domains of assessment in behavioral health practice must necessarily include physical-biological, affective, cognitive, and behavioral “targets”.  To make things more interesting (and complicated), these variables or “targets” must be assessed relative to not only the patient but also across various “environments” such as the family, the health care system, and the sociocultural context.  Once information is gathered about all of these relevant domains, it must be integrated in a concise and useful format to address the purpose of the assessment and provide answers.


Psychodiagnostic evaluation is a frequent activity of the behavioral health disciplines and may serve a number of purposes such as differential diagnosis, guiding a treatment intervention, and outcome assessment. One of the unique aspects of this type of assessment is the integration of the multiple domains of information as discussed above. A useful method for approaching the biopsychosocial assessment of any issue is to pose the questions in Table 1.  The questions can be used to develop the goals of assessment.   These were adapted from Belar, Brown, Hersch et al. (2001) relative to the self-assessment of readiness to practice in the area of clinical health psychology.  However, they provide an excellent template for building a biopsychosocial behavioral health assessment approach.



Table 1. Developing the Goals of a Biopsychosocial Assessment 



What are the biological bases of health and disease as related to this problem?  How is this related to the biological bases of behavior?


What are the cognitive-affective bases of health and disease as related to this problem?  How is this related to the cognitive-affective bases of behavior?


What are the social bases of health and disease as related to this problem?  How is this related to the social bases of behavior?


What are the development and individual bases of health and disease as related to this problem?  How is this related to the development and individual bases of behavior?


What are the interactions among biological, affective, cognitive, social, and developmental components (e.g. psychophysiological aspects)? 


Do I understand the relationships between this problem and the patient and his or her environment including family, health care system, and sociocultural environment?


Have I chosen empirically supported clinical assessment methods for these problems and how might the assessment be affected by information in questions 1-5?



Adapted from Belar, Brown, Hersch, et al. (2001, p. 137)



The process of biopsychosocial assessment includes determining assessment needs, choosing the appropriate methods of assessment, gathering information from all the relevant domains, formulating impressions, concisely and efficiently communicating results, and then following through as required.


A Model of Biopsychosocial Assessment


Biopsychosocial assessment varies widely depending upon a number of factors including:


·         the referral question

·         patient status

·         illness/disability issues,

·         the referral source, and

·         the treatment setting


Based on an extension of the biopsychosocial conceptualizations of Engel (1977) and Leigh and Reiser (1980), Belar developed a model for clinical health psychology assessment (Belar, Deardorff, & Kelly, 1987; Belar and Deardorff, 1995; 2009).  This model might be applied to any of the disciplines falling under the rubric of behavioral health including counseling, social work, nursing, medicine, etc.  As can be seen in Table 2 (Adapted from Belar and Deardorff; 2009, pp. 51-53), this model articulates targets of assessment by domain of information (biologic or physical, affective, cognitive, behavioral) and unit of assessment (patient, family, health care system, or sociocultural context).  Although by no means exhaustive, each block in the Table shows the kinds of information that needs to be gathered in an attempt to understand the patient from a biopsychosocial perspective.  In addition to current status, each block also has an associated developmental or historical perspective that may be important to fully understanding the problem being assessed.  For each block, the clinician should think in terms of assessing current status, changes since onset of the illness or disability, and past history. Also for each block, assessment should focus not only on identification of problems but also resources and strengths of the patient and his or her environment.



Table 2. Biopsychosocial Targets and Domains of Assessment















Healthcare System












age, race, sex, physical appearance, symptoms, health, vital signs, lab data, medications, genetics



home setting, economics, family size, family illness






Treatment setting, medical procedures, prosthetics





Social services, financial issues, social networks, occupational, health hazards









mood, affect, feelings about treatment and other aspects of chronic pain, history of affective disorder




family feelings about patient, illness, and treatment






providers’ feelings about patient, illness, and treatment






sentiment of the culture about patient, illness, and treatment










cognitive style, thought content, intelligence, education



knowledge about illness, attitudes and expectations




provider knowledge, provider attitudes


current state of knowledge, cultural attitude









activity level, interactions with others


involvement in care


provider skills, education, and training


employer, laws, customs


This model is useful for approaching any problem the clinician may be confronted with assessing.  It ensures that no domain of information is overlooked, facilitates decision-making about assessment strategies, assists in the organization of the information obtained, and, helps with the formation of intervention strategies.  The fact that the model is portrayed as blocks of information should in no way imply a reductionistic focus.  The information obtained within each block must be conceptualized as interrelated with all of the other compartments.


Patient Targets


Biological Targets.   The most basic biological targets include the patient’s age, race, sex and physical appearance.  Beyond these obvious variables, other information might include physical examination data, laboratory studies (e.g. blood, urine, imaging studies), medications, and drug use (current and past).  Other important information includes the patient’s medical history (e.g. illness, hospitalizations, surgeries) as well as that of his or her family. 


Affective Targets. Assessment of affective targets requires developing an understanding of the patient’s mood and affect, along with his or her feelings about the illness, treatment, health providers, future, and social support network. Keeping in mind a historical and developmental perspective, it is also important to assess the patient for possible long term emotional issues (e.g. dysthymia, generalized anxiety) as well his or her response to previous stressors.  This will help the clinician more fully understand the patient’s current status. 


Cognitive Targets.  The mental status examination usually forms the core of current cognitive assessment and includes such things as memory, concentration, and intellectual capacity.  Further assessment of cognitive function includes the patient’s thoughts, beliefs and attitudes especially about things related to the purpose of the evaluation (e.g. disease, disability, health behavior modification).  More global cognitive targets include religious beliefs and one’s world view.  All of these factors can help the clinician understand the patient’s knowledge about the illness, perceived meaning of the illness to the patient, attitudes about medical and other interventions, attitudes about health, perceived control over physical and psychological symptoms, and expectation about future outcome.


Behavioral Targets.  Behavioral targets include what the patient is doing (action) and the manner in which he or she does it (style).  Examples of actions include motor behaviors such as facial expression, foot tapping, bracing, body posture and eye contact.  Behavioral styles might include such things as flamboyant, hesitant, hostile, restless, and passive. Assessment of behavioral targets, including action and style, should give a clinician a good understanding of such things as the patient’s level of self-care, health-habits, use of the health care system, physician-patient interactions, current  and past compliance with treatment regimens, and vocational and avocation pursuits.


Interaction among Patient Targets


It is again important to underscore that although the targets of assessment are organized as “blocks” or “compartments” they are conceptualized as completely interactive and interrelated.  During the assessment, the clinician should always be thinking in terms of how the various findings interrelate.  For instance, the mental status examination results (cognitive) may be significantly impacted by medications (biological) and affective (depression) targets.  A common example is the assessment of back pain.  When assessing the pain, the patient might show minimal findings on MRI (biological), extreme disability, grimacing, and verbalizations of symptoms (behavioral) along with depression and anxiety (suffering or affective), because he or she thinks the pain is due to a spinal tumor or something that will cause harm (cognitive).  Integration of these targets of information will guide the multidisciplinary (biopsychosocial) intervention.  


Environmental Targets


As suggested in Table 2, each of the patient targets must be assessed and understood within the context of the environments within which the patient interacts: the family unit, the health care system, and the sociocultural context (social, work, cultural and ethnic background).


Family Environment. The physical domain of the family environment might include such things as development history, other illnesses in family members, the home setting, and any recent changes in any of these areas.  In the affective domain, it is important to understand family members’ feelings about the patient, the target of assessment (e.g. illness, health habit change such as smoking cessation or substance abuse), and the treatment rendered.  In the cognitive domain, the clinician should assess family members’ attitudes, perceptions, and expectations about the patient’s condition, treatment and future.  Overall intellectual resources and knowledge about the patient’s illness or condition should also be evaluated.  Evaluation of the behavioral domain might include such things as how family members act toward the patient especially in response to “illness behaviors” (e.g. appropriate, nurturing, enabling, punishing, and solicitous).  Also, any change in the behavior of the family unit, especially as a result of the patient’s condition, should be assessed.


Health Care System. Assessment of the physical domain of the health care system might begin with the environment in which the patient is being evaluated or treated since this can impact all of the other findings (e.g. intensive care unit, rehabilitation hospital, hospice, private practice office, home setting). Special consideration will include privacy issues, prosthetic aids, the degree of sensory stimulation coming from the environment, and the diagnostic tests to which the patient is being subjected.  Beyond the physical domain, the clinician must be aware of how the health care staff feels about the patient (affective) and his or her condition.  The cognitive domain of the environment includes the staff’s knowledge about the patient, the condition being treated, and their expectations for outcome. 


Unfortunately, medical mistakes are commonplace and often due to a lack of knowledge on the part of health care providers.  Assessing the behavior of the health care system requires that the clinician have an understanding of the policies, rules and regulations that will affect the patient’s treatment.  This might include such things as staffing patterns, infection control policies, and the discharge planning process. Of particular importance is the behavior of the health care providers toward the patient, especially in complex cases.  The patient may be evaluated and treated by a myriad of specialists, all communicating and behaving toward the patient in a different, and often inconsistent, manner.  This can create a very confusing situation for the patient and impede response to treatment.


Sociocultural Environment.   The physical aspects of the patient’s sociocultural environment include (a) the physical requirements of the occupational setting and (b) the social and financial resources available to the patient.  Assessment of the patient’s social network including size, density, proximity and frequency of contact is also important.  In the affective and cognitive realms of the sociocultural enviornment, the clinician should understand cultural sentiments, attitudes, and expectations regarding the patient’s race, gender, lifestyle, religion, illness and treatment.  Within the behavioral domain, assessment might include such things as employment policies relative to the patient’s problem, legislative policies related to health and disability issues, and ethnic customs related to illness, disease, and disability.


Interaction among Patient and Environmental Targets


As discussed previously, and I will emphasize again, the clinician should always be thinking in terms of how the various findings within each “box” interrelate.  To extend the example of the patient with back pain: the patient might show minimal findings on MRI (biological); extreme disability, grimacing, and verbalizations of symptoms (behavioral) along with depression and anxiety (suffering or affective), because he or she thinks the pain is due to a spinal tumor or something that will cause harm (cognitive); family members that are angry with him due to his disability (family environment) and loss of his job (occupational); doctors that will not take the time to reassure him regarding his condition (health care environment); and, ethnic customs that influence his expression of depression through increased pain (suffering) rather than directly (cultural environment).  If any of these pieces of information were to be missed in the assessment, the treatment plan and intervention would likely be inadequate with an elevated risk of failure.  




Stemming from the scientist-practitioner model, the behavioral health clinician completing an assessment should consider diverse sources of information and multiple types of data, using a convergent-divergent, hypothesis-testing approach.  In making choices about which assessment methods to employ the clinician will take into account a variety of issues including the purpose of the evaluation, the targets being assessed, the validity of the assessment method relative to the target, the setting in which the assessment will be completed, as well as feasibility and cost-effectiveness of the assessment approach.


Archival Data


Archival data might include (a) literature reviews about the condition being assessed and (b) the patient’s medical records history.   In the age of the Internet, completing a literature search relative to the problem being assessed is very efficient. The clinician can rapidly obtain information about the condition being assessed (cause, symptoms, course, prevention, treatment, psychological factors) and recommended assessment methods.  Archival data also includes the patient’s medical history and records (current and past).  Since most patients tend to be fairly poor historians, this data can be extremely valuable in giving the clinician an accurate picture of previously reported symptoms, what types of treatments have been attempted in the past and the patient’s response, and other healthcare providers’ impressions of the patient and problem being assessed.


Pitfalls.  Given the ease of access to the Internet, there is really no excuse for a clinician to not avail him or herself of this information resource.  The only pitfall might be access to full text articles rather than just abstracts of articles.  For those who have any association with a university, medical school, or hospital (e.g. clinical appointment, staff), full access to the institution’s online subscriptions is usually available.  For others, consideration might be given to subscribing to an online database.  More difficult is obtaining the patient’s past medical records and this might be considered a “pitfall” if not done.  Although not always necessary, in complicated cases it is certainly worth the effort.  In this age of time-pressured physicians of multiple specialties each treating a different “part” of the patient’s problem, it is not uncommon for important details (either current or historical) to be missed. I cannot count the number of times that the review of medical records has revealed information that the patient did not report during the clinical interview such as a treatment that has been effective in the past but was not being considered currently, a medication that is being considered but to which the patient had a previous terrible reaction, or significant inconsistencies in the patient’s report versus what is documented in the records.


Clinical Interview


The clinical interview is the sine-qua-non of assessment and the most common form for gathering information.  It is generally this initial source (and often the only source) of current and historical data across all domains (e.g. physical, affective, cognitive, behavioral) and environments.  The interview is also the initial step in forming what may be a working treatment relationship with the patient. The format of the interview will vary depending on the assessment purpose and range from unstructured to semi-structured to highly structured. The most common elements of the clinical interview include the presenting problem (e.g. symptoms, impact on function), history, psychosocial situation and history, occupational function, and some form of a mental status examination.  An example of a typical clinical interview structure can be found in Table 3.   However, the clinical interview is certainly modified depending on the patient population with whom the clinician is involved.  The clinician might decide to design a custom structured or semi-structure interview specific to the condition being assessed (e.g. pain, cancer, weight loss, diabetes, headache, etc.).  Examples of specific structured interviews can be found on the Internet and elsewhere.  The content and form of the clinical interview will vary greatly depending on the purpose and goal of the overall assessment.



Table 3.  Example of a Biopsychosocial Clinical Interview Structure



A. Reason for the Evaluation

B. History of the Present Illness

C. Past Psychiatric History

D. General Medical History

E. History of Substance Use

F. Psychosocial/Developmental History (Personal History)

G. Social History

H. Occupational History

I. Family History

J. Review of Symptoms

K. Physical Examination (or similar information)

L. Mental Status Examination (MSE)





Thought (Content & Process)




Level of Consciousness

Insight & Judgment

Cognitive Functioning & Sensorium

Knowledge Base

Endings — Suicidal & Homicidal Ideation

Reliability of Information

M. Functional Assessment

N. Diagnostic Tests

O. Information Derived From The Interview Process



Pitfalls.  Probably one of the greatest pitfalls related to the initial clinical interview is the clinician not establishing the beginnings of a trusting relationship with the patient while also gathering critical information in a timely fashion.  Depending on the purpose of the assessment, this can be particularly challenging for the non-medical clinician (e.g. psychology, social work, counseling) since patients are often seen within a primarily medical context.  Patients can be initially defensive when the “shrink” shows up, especially depending upon how the referral was framed by the referral source.  This reticence can often be overcome by initially focusing the interview on “medical” issues while also explaining the role of the behavioral health clinician in assessment and treatment.


After a successful initial interview, the patient should have a good understanding of the behavioral health clinician’s role in the assessment and treatment of the presenting condition.  Also, the patient should feel that he or she was fully “heard” and understood by the clinician while not feeling rushed.  On the other hand, the clinician should have obtained enough information necessary to form initial impressions and guide the rest of the assessment, while also engaging the patient in the beginning of the treatment process (as appropriate).  The ability to achieve these multifaceted goals, often in less than an hour, is certainly challenging.  Developing the interview skills to achieve these goals comes with practice and experience.




Questionnaires that are clinician-developed and problem-focused can be a very useful and efficient adjunctive method of gathering information.  In an outpatient setting, these can often be mailed to the patient prior to the initial evaluation appointment. The use of questionnaires can be a great time saver and often helps to provide more accurate information.  For instance, many questionnaires ask about current and past medications (along with response), past medical treatments, past and current healthcare providers with contact information, surgical history, etc.  Patients often cannot provide this information accurately, or at all, when asked as part of the initial evaluation in the office.  However, it is often readily available to the patient if he or she has time to collect it as part of completing a questionnaire beforehand.  The completed questionnaire that is brought to the initial evaluation can also help guide further information gathering.  Some examples of problem-focused questionnaires can be found in Table 4.  The Internet provides an almost unlimited resource for questionnaires that have been developed for various issues.



Table 4. Example of Problem-Focused Questionnaires



Pain Patient Questionnaire


University of Washington Diabetes Questionnaire


VCU Sleep Disorders Questionnaire


Stanford Chronic Disease Questionnaire


UPMC Weight Loss Questionnaire



Depending on the purpose of the evaluation, questionnaires can also be developed for significant others and health care providers.  The form and content of the questionnaire will depend on a variety of factors including the purpose of the evaluation, the type of treatment intervention, and the patient population.  Questionnaires might include a number of different types of inquiry methods including open-ended, forced-choice, checklists, simple rating, or pictorial diagrams (e.g. pain drawings). 


Pitfalls. When designing a questionnaire it is important to keep in mind the person who will completing it including such things as educational level, language, and disability issues that might impact ability to complete the assessment. The clinician who designs a 20-page questionnaire written in English at the graduate school level of reading comprehension using a 10-point font size, will likely be faced with very frustrated patients who, at their initial appointments, bring with them blank questionnaires and an appropriately defensive attitude toward the person who expected them to complete such a task.  To carry this hypothetical even further, imagine the target population is primarily elderly (possible visual problems) and Spanish is the primary language. 




As part of an initial assessment period, patients are often asked to complete diaries of behaviors that are both overt (e.g., pill taking, tics, walking distance, vomiting) and covert (e.g. thoughts, feelings, pain perceptions, blood pressure). These baseline measures are used as part of the initial evaluation to design the intervention and, later, to gauge the effectiveness of the treatment.  Diaries can often reveal important information about the frequency, intensity and duration of targeted behaviors.  They also can reveal information about antecedents, consequences, and relationships among internal and external behaviors.  Diaries can also be an important source of information to help assess the efficacy of a medical intervention.  For instance, when a patient is being considered for a spinal cord stimulator (SCS) implant for pain control, he or she typically undergoes a week-long temporary trial before permanent implantation is considered.  In routine practice, the criterion for a “successful” trial and permanent implantation is a 50% or greater reduction in pain.  Often, at the end of the week-long trial, the physician will simply ask the patient “Was your pain reduced by more than half?”  Research has demonstrated memory for pain is notoriously inaccurate and that there can be a significant placebo effect that may influence the patient’s assessment of the effectiveness of the trial results (resulting in permanently implanting a SCS that will not be effective over the long term).  To combat these problems, and provide better data for decision-making, I have patients complete a pain-medication-activity-mood diary for 2 weeks prior to the trial period and during the 1-week trial.  This type of data helps the physician (and patient) make a better decision about permanent implantation.


In this electronic age, the technology of diaries is rapidly moving from paper-pencil to other means (See Table 5).  Now, data collection through a diary method can be done in a variety of ways.



Table 5. Comparison of Diary Data Collection Methods



The Limitations of Paper Diaries



There are many paper pain diaries in use today. Unfortunately, they have limitations:


Paper diaries can be accidentally altered, damaged or lost.


It is difficult to share paper diaries with others and to update them as the condition changes.


Paper diaries cannot be effectively organized into reports, charts, graphs, notes etc. to provide a continuous and comprehensive overview of the condition.


Paper diaries cannot be time-stamped, which means that the exact date and time of entries is not recorded. This presents a problem for many healthcare professionals as it is difficult to determine when entries were made. From a medical perspective, not knowing when entries were made can greatly impact the usefulness of the information reported.


Paper diaries cannot be easily integrated into electronic medical records.



The Advantages of Electronic Diaries



Electronic diaries automatically time-stamp all entries, giving both the patient and doctor a reliable and verifiable record of when they were made.


The information recorded is always integrated with past entries to form a single, long-term, and detailed overview of the condition.


Electronic diaries make it possible to share up-to-date reports with doctors, family members, friends and other caregivers.


Securely store and access data from anywhere and at all times.


Summary reports are generated in charts, graphs, body map images and notes. These can be attached to medical records, either in print or electronic form, or saved by the patient as a personal health record.



Types of Electronic Diaries



Hand Held Device


Electronic data capture on a mobile device with a central system that allows for web review


IVR (Interactive Voice Response)


Keypad or voice data capture with a central system that allows for web review by site and sponsor


Internet Web Data Capture


Internet Web data capture with a central system that allows for web review by site and sponsor


Digital Pen


Digital pen that captures data and uploads to a central system that allows for web review; and




Electronic data capture on a tablet mobile device with a central system that allows for web review.



Pitfalls.  Compliance with completing diaries (paper-pencil) is probably one of the biggest obstacles to overcome to successfully use this assessment measure.  In one study (Stone et al., 2002), it was found that compliance with paper diaries was less than 20%.  This was defined as less than 20% of patients used the paper diary accurately.  Although the clinician might be tempted to assess a myriad of variables in the diary, it should be easy to use, nonintrusive and brief.  One of the biggest pitfalls is making the diary too complex and onerous for the patient to complete.  As reviewed in Table 5, technology is certainly helping with this issue and the day of the paper-pencil diary may be fading rapidly.  Electronic diary methods are becoming more commonplace (e.g. through smart phones, the Internet) or custom-made devices that require little patient effort to complete the tracking (e.g. activity during the day such as “up-time”, pill use, etc.).  One pitfall of electronic diaries is a lack of understanding of the technology by the user (patient).  Some patients are very fearful of this type of technology simply because they do not understand it.  This issue needs to be assessed and managed through proper education.  Simply doing an Internet search for these specialized electronic or software methodologies will provide a number of resources specific to the problem being treated.     




Psychometric instruments used for biopsychosocial assessment related to health might be categorized as four general types:


  • Broadband-General
  • Broadband-Health
  • Narrow Focus
  • Narrow Focus – Health


Examples of each of these types of instruments can be found in Table 6.  



Table 6. Examples of Psychometrics used in Biopsychosocial Assessment






Minnesota Multiphasic Personality Inventory  (MMPI-2; MMPI-3)


Personality Assessment Inventory (PAI)

Symptom Checklist - 90R (SCL-90R)

Millon Clinical Multiaxial Inventory (MCMI-III)






Millon Behavioral Medicine Diagnostic (MBMD)

Battery for Health Improvement – 2 (BHI-2)

Sickness Impact Profile (SIP)

Primary Care Evaluation of Mental Disorders (PRIME-MD)


Health Locus of Control (HLC)



Narrow Focus-General



Beck Depression Inventory – 2 (BDI-2)

Beck Anxiety Inventory (BAI)

Post-Traumatic Stress Diagnostic Scale (PDS)




Narrow Focus-Health



Multidimensional Pain Inventory (MPI-3)


Cancer Inventory of Problem Situations


Eating Disorder Inventory – Third Edition (EDI-3)



The broadband-general measures include those that were not originally designed to assess medical patients or health-related issues. These measures often assess a number of personality, behavioral or other variables.  These assessments were not originally designed to assess medical or health issues, but often normative data for specific populations has been developed to help with generalizability.  The Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Graham, Ben-Porath et al., 2001) is the most widely used and researched personality inventory.  The MMPI-2 was designed to identify psychopathology and personality features; however, it is also one of the most commonly used measures used in clinical health psychology for such things as chronic pain, pre-surgical screening, and other issues.  When using broadband-general measures in clinical health psychology practice, the clinician must be well-versed in validity, standardization, and interpretation issues to avoid misuse of the test.   Example excerpts of three different interpretations of a 1-3/3-1 codetype on the MMPI-2 illustrate this point:



Table 7. Different 1-3/3-1 Codetype Interpretations on the MMPI-2





The traditional interpretation is often computer generated as part of an interpretative report.  Classic conversion symptoms may be present, particularly if scale 2 is considerably lower than scales 1 and 3 (the so called conversion-V pattern).  Whereas some tension may be reported, severe anxiety and depression usually are absent.  The somatic complaints include headaches, chest pain, back pain, and numbness or tremors in the extremities.  Other physical complaints include weakness, fatigue, dizziness, and sleep disturbance.  The physical symptoms increase in times of stress, and there is clear secondary gain associated with symptoms.  These individuals present themselves as normal, responsible, and without fault.  They make excessive use of denial, projection, and rationalization, and they blame others for their difficulties.  They tend to be rather immature, egocentric, and selfish.  They are insecure and have a strong need for attention, affection, and sympathy.   They are very dependent, but they are uncomfortable with the dependency and experience conflict because of it. Although they are outgoing and socially extroverted, their social relationships tend to be shallow and superficial, and they lack genuine involvement with other people.



Chronic pain


Patients with similar profiles present with a wide variety of vague and diffuse somatic complaints.  In these cases, there is often a very low correlation between subjective and objective findings.  These patients show pain behaviors and somatic complaints far beyond what would be expected due to nociceptive input and objective findings.  These patients show a high readiness to admit pain behaviors, but very little emotional distress associated with their reports of pain and other symptoms (low Scale 2).  From a positive reinforcement perspective, given the “readiness to emit pain behaviors” there is an increased chance of the patient “using” the pain behaviors to influence his or her environment or of pursuing reinforcing social consequences.  From a negative reinforcement perspective, these patients will often use complaints of pain to extricate themselves from stressful situations.  Extreme elevations on Scales 1 and 3, in conjunction with a non-clinical elevation on Scale 2 (depression) suggest that this patient is not uncomfortable in the sick role and may find aspects of it reinforcing.  As such, the patient is showing a high readiness to admit pain behaviors, along with multiple somatic complaints, in conjunction with minimal distress regarding these symptoms.  (Note.  If scale 2 is elevated at or above  1-3, then the patient is expressing distress about being in the sick role or being unhappy and uncomfortable with his/her pain behaviors and, hence, is not as likely to find them reinforcing.  This profile suggests less of an influence of environmental contingencies.)



Spine Pre-Surgical Screening 


As discussed by Block, Gatchel, Deardorff, and Guyer (2003, page 83), elevations on Scales 1 and 3 reflect excessive sensitivity to pain rather than the cause of the pain.  In other words, in the face of a certain level of nociception, individuals who have high scores on Scales 1 and 3 are more likely to experience high pain levels, and to be more functionally disabled than those with low scores on these scales.  As such, pain sensitivity as assessed by Scales 1 and 3 seems to predispose patients towards negative spine surgery results even when the surgery corrects the underlying pathology (Block et al., 2003, page 84).  Individuals with this profile tend to respond very poorly to interventional and invasive pain management techniques aimed at identifying and “fixing” a physical pain generator.  The reason they do so poorly is that the other non-physical factors continue to impact their perception of pain and suffering. 



The broadband-health measures are measures that have been specifically developed to assess a number of issues related to health and medical issues, without necessarily focusing on one particular health problem.  Examples can be seen in Table 6.  These tests will often assess psychological and behavioral issues that are intimately related to medical treatment.  For instance, the Battery for Health Improvement-2 (BHI-2; Bruns and Disorbio, 2003) is designed “for the psychological assessment of medical patients” and includes scales organized into five domains: validity, physical symptoms, affective, character, and psychosocial variables.  Similarly, the Millon Behavioral Medicine Diagnostic (MBMD; Millon, Antoni, Millon, Minor and Grossman, 2001) includes domains of response patterns, psychiatric indications, coping styles, stress moderators, treatment prognostics, management guides and negative health habits.  The MBMD now has normative data for general medical patients, chronic pain and bariatric surgery candidates.  


The narrow focus measures include measures that assess a particular psychological issue such as depression, anxiety, suicidality, stress and coping.  Probably two of the most commonly used measures in this category are the Beck Depression Inventory (BDI-2; Beck, Steer, & Brown, 1996) and the Beck Anxiety Inventory (BAI; Beck and Steer, 1993).  Similar to the MMPI-2, when these measures are used with medical patients one must be very cautious with interpretation.  For instance, the BDI-2 is a measure of self-rated depression that contains a number of physical (e.g. weight, sleep, energy) and cognitive (concentration, memory) symptoms, all of which can be differentially affected by depression, pain or some other medical condition, or both. Therefore, the clinician should always be aware of the impact of the actual medical problem on the narrow focus psychological instrument.


The narrow focus-health test is designed to be a brief measure of a specific medical or health condition (See Table 6).  These tests are valuable for the clinical health psychologist assessing and treating a specific condition.  Examples of these tests have been developed for the assessment of chronic pain (often used in conjunction with some of the broad based measures).  For instance, the Multidimensional Pain Inventory (MPI; Kerns, Turk, & Rudy, 1985) includes 13 scales that yield assignment to one of three profiles based on cluster analysis: Dysfunctional, Interpersonally Distressed, and Adaptive Coper.


Pitfalls.  One of the primary pitfalls in psychometric assessment related to health problems has already been alluded to: not paying attention to the validity of the test instrument relative to the problem being assessed along with concomitant interpretation issues.  It is always important to keep in mind standardization and basic psychometric issues when using any test on a medical patient population or to address health issues. 


A second pitfall is not adequately preparing the patient for taking these types of tests, including the purpose of the test.  Problems can really occur when a medical patient is confronted with the types of questions on a broadband-general type of test (e.g. MMPI-2) without any preparation as to why the test is being prescribed.  Simple preparation of the patient (e.g. purpose of the test, brief instructions, etc.), can avoid problems and generate more useful results. 




Observation is one of the most fundamental methods of assessment for the behavioral health clinician. Observation can be unstructured such as noting what occurs during the clinical interview, or within the assessment setting (e.g. office waiting area, hospital room, etc.). It can also be highly structured such as having the patient complete a specific functional task (e.g. self-administration of insulin, walking down the hallway without assistance, etc.).   Observation can be made directly by the clinician or by others (family member, health care providers) and might be recorded (video, audio).  Highly structured observation is often done in conjunction with research projects, and the results are quantified through the use of validated rating methods for very specific behaviors (e.g. pain behaviors).


Pitfalls.  One of the primary pitfalls of observations is the clinician either ignoring this valuable assessment domain altogether or not integrating (e.g. compare and contrast) it with other data sources.  I will commonly integrate pain behavior observation with that of self-report data in evaluating a patient with chronic pain.  For example, I recently evaluated a pain patient who showed significant pain behaviors walking from the waiting room to the office (limping, using the wall for support, periodic pauses) and during the first 10 minutes of the interview while seated (grimacing, shifting positions, guarding).  However, after about 15 minutes into the 2-hour interview, the patient’s pain behaviors remitted, his movements became quite fluid, and he remained seated the entire time.  In addition, the patient rated his pain “at the time of the interview” at a 9 out of 10 (0-10 scale). Clearly, these data are not consistent and must be taken into account.  Another pitfall is not taking into account observation data relative to the interaction among family members during the evaluation process (when this data is available). This can tell the clinician a lot about what is going on in the naturalistic environment.


Psychophysiological Measures


Psychophysiology refers to the “scientific study by nonsurgical means of the interrelationships between psychological processes and physiological systems in humans” (Cacioppo, Petty & Marshall-Goodell, 1985, p. 264).  Psychophysical measures have become very sophisticated with advancements in technology and include such things as electromyography (EMG; changes in muscle activity), cardiovascular measures (heart rate, beats per minute, heart rate variability, vasomotor activity), skin conductance (galvanic skin response, skin conductance response), electroencephalography (EEG; and evoked potentials) and functional magnetic resonance imaging (fMRI). The psychophysiological measures provide assessment and treatment approaches for a variety of conditions (the treatment often comes under the rubric of biofeedback).  With the advent of sophisticated equipment, psychophysiological treatment approaches (e.g biofeedback) have been enhanced through such things as what measures are available to the patient in terms of feedback and how certain stimuli of interest (e.g. desensitization of phobias) can be presented (e.g.  The technology has gone far beyond the “old days” of having the patient imagine coming close to a snake.  Now, through the use of virtual reality technology the presentation of almost life-like images is possible and can be controlled by the patient during the treatment process).


Pitfalls.  Probably the greatest pitfall in using this approach is a lack of appropriate training on the part of the clinician along with inadequate treatment interventions including a disregard for paying attention to generalizing effects outside of the office.  Almost any professional can purchase very sophisticated equipment with little or no advanced training or certification (e.g. EEG biofeedback).  The same (unethical) clinician can then begin marketing his or her practice as specializing in the “disorder du jour” such as EEG neurofeedback treatment of ADHD without really having any expertise in that area.  In these cases, the patient is often simply “hooked up” to the equipment and told to practice a pre-programmed sequence of tasks.  Research has demonstrated that when these approaches are used properly, they can be very powerful interventions.  However, the technology can often be very seductive leading to inappropriate and ineffectual interventions in the actual clinical setting.  Secondarily, even when used appropriately in the clinic setting, generalizing treatment results to the naturalistic environment may be an afterthought if addressed at all.




As discussed by Belar and Deardorff (2009, p. 79), at the end of the assessment process, the clinician should have an understanding of:


(a) the patient in his or her physical environment

(b) the patient’s relevant strengths and weaknesses

(c) the evidence for psychopathology

(d) the nature of the disease and treatment regimen

(e) the coping skills being used 


Upon completion of the assessment, and integrating the data, the clinician should be able to answer the following questions (adapted from Moos, 1977 as reprinted from Belar and Deardorff, 2009, p. 79).



Table 8. Comprehensive Understanding: The Goal of Assessment



How is the patient dealing with pain, incapacitation, and other symptoms?


How is the patient dealing with the hospital (clinic, hospice, or other) environment and the special treatment procedures?


Is the patient developing and maintaining adequate relationships with the health care staff?


Is the patient preserving a reasonable emotional balance?


Is the patient preserving a satisfactory self-image and maintaining a sense of competence and mastery?


Is the patient preserving relationships with family and friends?

How is the patient preparing for an uncertain future?






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