Beyond the Biopsychosocial Interview

The biopsychosocial interview as used in treating addictions originated more than 50 years ago to evaluate persons presenting for the treatment of alcohol problems. Most of the treatment programs that existed at that time focused only on alcohol. The interview was a way to structure a conversation between the patient and counselor, whose primary credential at the time was being sober at least six to twelve months. The objective of the conversation essentially was for the counselor to determine if the individual being interviewed had as much a problem with alcohol as the counselor had before achieving sobriety.

The biopsychosocial interview originated when there was essentially no exact definition or criteria for diagnosing alcoholism. The DSM-II published in 1968 had four paragraphs dedicated to the description for the types of “alcoholism” and one paragraph for “drug dependence” – all on the same page. There was another half a page for listing the codes for different drugs for which one could be dependent. The DSM-II was used until 1980 when the DSM-III was published.

Over the years, there were probably more versions of a biopsychosocial interview than there were clinicians. Having observed counselors doing intakes and reviewed countless biopsychosocial interview forms, the obvious conclusion is that there has been no consistency in what constitutes an assessment of what defines the different substance use disorders. The other problems with the traditional biopsychosocial interview was that it was not necessarily efficient and frequently delved into areas of historical and social situations that would be better address once the individual had engaged in treatment. The “interview” actually became more of a concept than a structured way of conducting an assessment.

The appropriate approach is to first determine what conditions are present and then determine the proper course of treatment. If the clinician does not identify the conditions to treat, the treatment plan will be prematurely designed. The DSM-5 provides criteria for identifying the mental health and substance use disorders. This identification can most efficiently be done by systematically covering the common conditions via a structured interview based on the DSM-5.

Having identified what conditions require treatment, the next step is to develop a treatment plan. The ASAM Criteria provide six dimensions that need to be considered in developing the treatment plan given that the conditions to be treated have been identified. There seems to be a tendency among some to jump to the development of a treatment plan before fully exploring the conditions to be treated.

Another error is to confuse a screen with a diagnostic assessment. A screen is just a means of establishing a probability of a given condition being present. It should be cheap, fast, and easy to use. An assessment, on the other hand, should be comprehensive, thorough, and as definitive as possible. Screens are helpful in leading to the appropriate assessment, but should not be used for making other substantive clinical decisions.

The bottom line is that the traditional biopsychosocial interview is a dated strategy that should be replaced with a sequential procedure of diagnostic assessment followed by the development of a treatment plan based on the DSM-5 and ASAM Criteria respectively. Such a sequence is the norm for mental health and medical practice in general.