Frequently Asked Questions:
Biopsychosocial Assessment

How do I ask about sensitive topics (e.g., trauma, substance use) during the assessment?

Asking about sensitive topics like trauma, substance use, self-harm, or abuse is an essential part of a comprehensive behavioral health assessment—but it must be done with care, compassion, and clinical intention. Clients may feel shame, fear, or mistrust around these subjects, especially if they’ve had negative past experiences with disclosure.

A trauma-informed approach prioritizes safety, autonomy, and cultural humility while still gathering the information needed for accurate diagnosis and effective treatment planning.

Principles of a Trauma-Informed Approach to Sensitive Topics

  1. Safety: Create a calm, nonjudgmental space that helps the client feel emotionally secure.

  2. Trust and Transparency: Explain why you're asking and how the information will be used.

  3. Choice and Control: Let clients know they can choose what to share and can pause or skip any question.

  4. Collaboration: Frame the assessment as a shared process to support healing and goals.
  5. Empowerment: Acknowledge the client’s strengths, resilience, and capacity for self-determination.

General Scripts for Introducing Sensitive Topics

  • “I’m going to ask some questions about your past experiences, substance use, and other areas that may have affected your well-being. Some of these questions may feel personal, and that’s okay—if there’s anything you’d prefer not to answer, just let me know. We can go at your pace.”
  • “These questions are never about judgment—they help me understand what you’ve been through so I can support you in a way that feels safe and useful.”

Examples of Sensitive Topics and How to Ask About Them

1. Trauma and Abuse History

Why it matters: Unresolved trauma can impact mood, behavior, relationships, and physical health.

Trauma-Informed Script:

“Sometimes people have gone through things that were overwhelming, frightening, or left a lasting impact—like abuse, neglect, or violence. Have you ever experienced anything like that?”

Follow-up options:

    • “Was there anyone you felt safe talking to about that at the time?”
    • “Do you feel like that experience still affects you today—in dreams, relationships, or how you feel about yourself?”

Key Tip: Avoid graphic detail unless clinically necessary. Validate disclosure and avoid rushing into trauma processing during the intake.

2. Substance Use

Why it matters: Substance use may be a coping strategy, co-occurring disorder, or safety concern.

Script:

“Many people use substances—like alcohol, cannabis, or other drugs—to cope with stress, sleep, or emotions. What’s your experience with any of those?”

Follow-up prompts:

    • “How often do you use, and how does it affect your mood or functioning?”
    • “Have you ever tried to cut back or stop? What happened when you did?”

Normalize first:

“This is something I ask all clients—not because I’m assuming anything, but because it’s important to understand the whole picture.”

3. Suicidal Thoughts or Self-Harm

Why it matters: Early detection is critical for safety planning and treatment decisions.

Script:

“When people go through really difficult times, it’s not uncommon to have thoughts of not wanting to be here. Have you had thoughts like that recently—or in the past?”

Follow-up:

    • “Have you ever made a plan or taken action to harm yourself?”
    • “What’s helped you get through those moments in the past?”

Important: Ask directly and calmly. Use a matter-of-fact tone to reduce shame and stigma.

4. Domestic Violence or Relationship Abuse

Why it matters: Intimate partner violence (IPV) can affect mental health, safety, and access to care.

Script:

“Has anyone in a relationship ever hurt, threatened, or tried to control you in ways that felt unsafe or left you feeling afraid?”

Frame as routine screening:

“I ask all clients about relationship safety because it’s a common and often hidden source of stress and trauma.”

What to Do If a Client Becomes Distressed

  • Slow down and validate:
    “It’s okay if this feels overwhelming—we don’t have to talk about everything today.”
  • Offer grounding:
    “Would it help to take a few deep breaths or take a short break?”
  • Reaffirm control:
    “You’re in charge of what you share and when. We can come back to this another time.”

How ICANotes Supports Trauma-Informed Assessment

ICANotes provides:

  • Pre-scripted, clinically appropriate prompts for trauma, substance use, and risk assessment

  • Customizable templates so clinicians can document disclosures sensitively and accurately

  • Risk and safety flags that help you track high-risk disclosures and document next steps

  • Integrated screening tools (e.g., PHQ-9, C-SSRS, ACEs) to support structured but respectful inquiry

Using ICANotes, clinicians can balance efficiency and empathy, ensuring comprehensive documentation while maintaining a trauma-informed tone throughout the intake process.

Final Tips

  • Ask permission: “Would it be okay if I ask you a few questions about your past experiences?”

  • Use clear, simple, and compassionate language

  • Document sensitive disclosures objectively, without judgment or excessive detail

  • Follow up with referrals, safety planning, or further assessment when needed

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