Biopsychosocial Assessment

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Biopsychosocial Assessment Part A and B

Therease Taylor
Wayne State University
SW3020: Social Work Practice Methods
Professor Lois Garriott

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Presenting Problem

Sheila Blake (pseudonym) is a forty-six-year-old black female who is currently living

with her stepfather. She has one son who is twenty-five years old he lives with his girlfriend.
Currently, she is single and has not been in a relationship in the last couple years. She is working
full time as a caregiver in the patients home. Ms. Blake was forced to move back home because
she lost her residence for back taxes last year. Her home was sold in the county auction last
October. She admits that she has a problem with gambling. Every other week when she is paid
she goes to the local casino and gambles her entire paycheck. She says she gambles because she
does not feel that her paycheck is enough money. She says she often wins, but she never leaves
so she loses all the winnings and what she started with. She will stay in the casino for the entire
weekend trying to at least win back what she started with. She admits that she never gets back
what she started with so she leaves the casino with no money and have to go two weeks until she
is paid again. This is repetitious each pay period this occurs. According to Ms. Blake, this
situation has caused much stress for her and her family she has lost everything she has worked
for including her home and car. Ms. Blake also says she feels angry all the time and her family
says all she does argue about any and everything.
Family of Origin History
Ms. Blake's mother was twenty-five when she had her. When she was born her mother
already had two sons from a previous marriage. Her mother and father were married and later
moved from Miami Florida to Detroit Michigan in the 60s. Ms. Blakes father was very abusive
to her mother which led them to divorce in 1969. Her mother later had another daughter who is
six years younger than she is. Ms. Blakes mother distanced from her sisters father and met a
gentleman who she married and remained married to until she passed away in March of 2006.

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Ms. Blake also lost her father in the late 80s. She says she is still grieving the death of
her mother. Ms. Blakes older brother George (pseudonym) is 50 years old and he is
incarcerated. He has been in and out of jail since he was a teenager for theft and burglary, he
does not have any children. Her next oldest brother is Todd (pseudonym) he is unemployed and
he also lives at home with their stepfather. He has five children and there are three different
mothers. Her youngest sister Tracy (pseudonym) is 41 shes married, employed and has two
children. Ms. Blakes mother does not have any children with her step father. Ms. Blakes mother
never worked outside the home much she was home mostly. She looked after her younger sister a
lot when they were younger. Ms. Blake says her mother was a disciplinarian and she can recall
being whooped and put on many punishments when she was a teenager. She admits her mother
was much harder on her when she and her siblings were younger. She says as she became an
adult she and her mother became very close. Ms. Blake does not have any family other than her
siblings and stepfather in Michigan all her living relatives are in Florida. When her mother and
father moved to Michigan it was just them and the children.
She can recall growing up she enjoyed the neighborhood she lived in and her friends. She
says her familys favorite holiday is Christmas. Christmas is a traditional time for her family that
is celebrated the same way every year. Her family use to gather at her parents' home for
Christmas, but for the last sixteen years everyone meets up at her younger sister's home.
Everyone is present to open gifts as they pass them out one by one in a circle. After all the gifts
are open her stepfather spends time with each one of the young children helping them open and
play with their toys. Ms. Blake describes all types of food that they eat on Christmas. I could
hear the excitement in her voice. Before her mother passed Ms. Blake said they would go to
Kensington Park for the 4th of July every year since she was a little girl for a big cook out with

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family and friends. She says their last gathering together at the park was last year because the
family that went with them for the last thirty years mother passed April of 2012. She expressed
that it was very emotional to continue the tradition going to the park on the 4th of July because
the two ladies who led it are gone. She said they celebrate almost every holiday at her sisters
house if her sister plans something.
Ms. Blake son and nephew were badly burned in a fire in May of 1998. The boys were
six and seven years old. Ms. Blake says her son took a lighter out of the house and went in the
backyard of their home where he found a very old gas can. He took the top of the gas can
pretending to bar-b-que. There was not any gasoline in the can, but because the can was so old
when he lit the lighter the fumes ignited. Her son immediately caught on fire, her nephew who
was six at the time attempted to put his cousin out with his own bare hands, but his hands caught
on fire. Shortly the boys went running out of the backyard on fire. Her son ran home in a ball of
flames neighbors rushed in the house with him. She put him out in the bath tub in a panic. Her
nephew ran up the block by this time the flames had spread from her nephews arms and hands to
his face. A neighbor was watering her grass when she seen him running up the street on fire she
grabbed him and put him out with her water hose.
Ms. Blake expressed that she felt responsible because she had been asking her landlord to
get rid of all the old and dangerous things he had in the shed in her backyard. The boys recovered
after many surgeries and skin grafts that they received until they were 18 and 19 years of age.
The surgeries were done at the Shiners Hospital in Cincinnati Ohio. She says both boys live
normal lives, but they are scared and she believes they are mentally affected from the trauma.

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Ms. Blake's sons father is still in the picture, but she feel that he failed her son when he was
growing up. Over the years, she has been in constant conflict with her sons father and his wife.
There is also constant conflict between Ms. Blake and her younger sister. She didnt go into
much detail about the conflict between involving her sister she just said they dont get along. She
says her sister is doing well for herself and she praised her, she expressed that she truly loves her
sister, but her sister walks a straight line. She says her sister always help her find employment
and is the stable one in the family. Ms. Blake has a very small family here in Michigan she has
never really had any conversations about death. She expressed that she maybe still grieving from
her mothers death.
Developmental History
Ms. Blake says her mother had a normal pregnancy with her. There were no health issues or
concerns. Her mothers pregnancy with her was full term with no complications. Her birth
weight was 6 pounds and 10 ounces. She was bottle fed when she was a baby there were no
developmental delays. She walked, talked and adjusted to all formalities of growth at a normal
age.
Health History
At birth Ms. Blakes heath was good she started her menstrual cycle at twelve. When she was 18
her appendix ruptured and she had to have it removed. Ms. Blake has never felt so much pain in
her life. She could still recall how much pain she was in. Ms. Blake does not enjoy going to the
doctor, health physical and mammograms are not up to date. She has eczema a skin condition
that she suffers from that often appears on most of her body. She has not had any insurance up
until recently when she was approved for state medical assistance.

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Substance Use / Abuse History

Ms. Blake explained that she smoked marijuana as a teenager but has not smoked any in over
twenty plus years. She does not have a drug problem and only takes over the counter Benadryl.
Ms. Blake does not mention any history of physical or mental abuse. She expressed that all she
really does is smoke cigarettes and drink alcohol occasionally.
Mental History
Client states that she has never had or experienced any mental issues, or received treatment or
assessments for any mental concerns. She says she never felt like her sanity was threatened.
Legal History
Ms. Blake does not have any legal issues other than a few traffic tickets and her drivers license
is suspended.
Immigration Issues
Ms. Blake does not have any immigration issues. She is a legal citizen born in the United States.
Relationship/Sexual History
Ms. Blake has one close friend that she has known for sixteen years. They met on the job where
they worked together at a detention facility. Other than Marie (pseudonym) she only associates
with people she has met at the casino. She had a few friends over the years, but they drifted
apart. She has never been married and currently single. She has dated a couple men, but the
relationships did not last. She says she has trust issues that interfered with her male partner when
she was in a relationship. Ms. Blake says she is not sexually active at this time and it appears
that her body is going through menopause. She says she has never had any STDs, or abortions.

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Family of Creation History

Her most recent experience in dating was with a gentleman who she met at the casino. Later she
found out that he lived with another woman, at this time she is not dating. Ms. Blake has been in
three long-term intimate relationships in her life. The last real relationship she was in ended
because she could not stay away from the casino. This was with a man she dated for twelve
years; she says she believes that he was her soul mate.
Religious History
Ms. Blakes religion was Baptist, but after her mother passed she joined a Nondenominational
Church. She has not attended church services in the last few years. She says she lost her faith
after her mother passed because she can't see why God would allow her mother to die. She met a
young man who believes in the stars and that is where her interest has been focused spiritually.
Growing up she was deeply involved in the church as well as the rest of her family. At this time,
Ms. Blake is not practicing a religion.
Educational history
Ms. Blake did not graduate from high school she admits that she was young and the school did
not interest her. She had a boyfriend who she truanted from school a lot with until she eventually
dropped out. In the early 90s she graduated from Lawton Business School, but she never
worked in that area. She has not had any other education other than certifications through her
employers.

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Employment History

Ms. Blake has had several jobs as a private duty caregiver. These jobs paid extremely well and
she was able to maintain comfortable living. Her last well paid caregiver job she lost due to her
showing up late for work and being nonproductive due to her gambling addiction. She has relied
on her sister to help her find jobs for the last five years as a caregiver.
Financial History
Ms. Blake has had good paying jobs in the past that she profited from. She has received three
settlements of large sums of money. Due to her gambling addiction she has gambled all her entire
estate. When she was in her early twenties she sewed her employer where she worked for sexual
harassment. A few years ago her employer was extremely fond of her and left her something in
his will. Her son also received a settlement from being burned on her landlords property that he
was supposed to receive when he turned eighteen. He did not receive his money because she
gambled it before his eighteenth birthday. She says the money was supposed to be bonded and
secure with no way to access it.
Strengths
Ms. Blake states that she has resilience and drive. She says she is strong, determined and a
people person. She loves taking care of people and has a tremendous amount of patience. Ms.
Blake says she is opened minded and has dignity and integrity. Ms. Blake has a very supportive
family system and at this time she is maintaining a stable job full-time job.

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Part B:

Step 1: Working with the Client

In this session, Ms. Blake spoke with me about some of the problems she would like to work on.
They are listed below:
1. She believes gambling will add to her income.
2. She lives with her father because she lost her home.
3. Her family says she does argue which is cause stress.
4. She is taking the bus to and from work.
Step 2. Prioritize the Problems
1. She is struggling because of her gambling
2. She lost her home
3. Conflict with her family
4. Taking the bus can be dangerous.

Step 3: Translate problem into Need

Problem
1.
2.
3.
4.

She is struggling because of her gambling

She lost her home
Conflict with her family
Taking the bus can be dangerous

Need
Treatment for gambling problem
Resources to find a home
Work on conflict with her family
Reliable and safe transportation

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Step 4. Evaluation Levels of Intervention for Need

Need # 1: Treatment for Gambling Addiction
Micro Strategy:

Start weekly sessions with the client to set goals for a gambling problem.

Pros:

The client has a supportive family system that will stick with her through treatment.
Treatment will help her through this gambling addiction.

Cons:

When the client has money all she thinks about is gambling.
Client has transportation problems

Clients Strengths:

Ms. Blake is open to therapy and treatment.

She is able to maintain her full-time job with her addiction.

Mezzo Strategy:

Arrange for client to attend weekly support group meeting

Pros:

Ms. Blake's adult son is willing to attend individual and group meetings with her.
She can purchase a monthly bus card that will allow her to make it to the meetings.

Cons:

On clients pay day she goes from work directly to the casino.
Ms. Blake is paid in cash every two weeks.

Macro Strategy:

Assist client with steps to band herself from the local casinos.

Clients Strengths:

Ms. Blake does show remorse regarding her addiction.

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Need # 2: Resources to find a home

Micro Strategy:

Assist client with entering into a group for financial assistance.

Pros:

Ms. Blake has primarily taken care of herself and has had her own home up until the last

year.
Moving back into her own place will give her a since of peace and independence.

Cons:

Ms. Blake has ignored all responsibility when she had her own home financially.
She put gambling before she paid her bills.

Mezzo Strategy:
Pros:

Ms. Blake is willing to attend group sessions regarding her situation.

She appears focused when talking about making progress.

Cons:

Ms. Blake has trouble with following through with goals.

The client knows that she can live with her father.

Macro Strategy:

Assist client with local resources for community base living.

Pros:

There are low-income housing and apartments in the clients community.

Ms. Blake is willing to make a fresh start even if it means a small apartment.

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Cons:

Ms. Blake says she would like a big enough place for her son.
She has never lived in an apartment.

Clients Strengths:

Ms. Blake says she is willing to sacrifice for change in her life.

Need # 3: Work on conflict with her family

Micro Strategy:

Meet with the client regarding her anger issues.

Pros:

Ms. Blake does have a relationship with her family.

Ms. Blake has a small family.

Cons:

Ms. Blake has anger issues that interrupt communication in the family.
The client yells a lot and does not like to hear the opinions of others in the family.

Mezzo Strategy:

Ask family members to attend weekly sessions.

Pros:

Ms. Blakes family is willing to be involved with her treatment.

Her family is very supportive.

Cons:

The family has trouble with confronting client about her problems because of her anger.
The sister and father are the only family members with transportation.

Biopsychosocial Assessment
Macro Strategy Does not apply
Clients Strengths:

Ms. Blake cares about her family well-being.

Need # 4: Reliable and safe transportation

Micro Strategy:
Obtain resources to assist Ms. Blake with finding resources for a vehicle.
Pros:

Ms. Blake has had vehicles in the past.

The client has made car payments in the past.

Cons:

The client does not have an active driver's license.

The client has traffic tickets to pay before her license can be reinstated.

Mezzo Strategy:

Involve family with goals for Ms. Blake to get a vehicle.

Pros:

Clients father is willing to assist her with paying her traffic tickets.

Clients sister is willing to give her a vehicle if treatment goes well.

Cons:

The family has lost financial trust in Ms. Blake

Ms. Blake has lost touch with financial responsibility.

Macro Strategy Does not apply

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Clients Strengths:

Ms. Blake is aware that change has to happen in order for her situation to get better.

Step # 5:
Goal number one To start individual weekly sessions with Ms. Blake to set goals for gambling
addiction.
Objective number one- Meet with Ms. Blake to assist with setting goals and build schedule
for individual weekly therapy sessions within 3 days.
Task number one Ask Ms. Blake to come in to discuss the plan of action 1day.
Task number two Gather literature, various documented information regarding gambling, and
implement online resources for gambling addiction within to use in individual sessions 2 days.
Task number three - Arrange for Ms. Blake to attended weekly group meeting for gambling
addiction 3 days.
Objective number two - Individual Sessions with Ms. Blake
Task number one - Ms. Blake will engage in individual weekly sessions with the Social Worker.
Task number two - Client will be involved with online tutorials that will assist with treatment.
Task number three - Client will engage in weekly group sessions for gambling addiction.
Goal number two Resources To find a home
Objective number one Find local agencies within the community that will assist Ms. Blake
with applications for low-income and affordable housing.
Task number one Contact Local housing and apartment units in Ms. Blakes surrounding area
within one week.
Task number two Search online for resources for community-based housing or apartments
within one week.
Task number three Visit local community centers to obtain information on housing assistance
within two weeks.
Objective number two - Ms. Blake will obtain applications from the local housing authority.

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Task number one - Ms. Blake will obtain section eight and low-income apartment applications
from the city Detroit and Habitat for Humanity within two weeks.
Task number two Ms. Blake will ask questions regarding her situation to the agencies
representatives upon picking up applications.
Task number three Ms. Blake will complete and return the applications to the agencies within
two weeks.
Goal number three Work on conflict within the family.
Objective One: Arrange for the family to be involved in family sessions.
Task number one Arrange for family members to come in for the weekly session within one
week.
Task number two Ms. Blake will make an outline of her personal family conflict to bring to
session within two weeks.
Task number three Ms. Blake will attend an anger management group within two weeks.
Objective Two:
Task number one Ms. Blake will revisit her outline on a daily basis to see if she is making
progress.
Task number two Ms. Blake will make arrangements with her family for the weekly session.
Task number three Family will engage in weekly sessions and role play that will help with
conflict.
Goal number four Address Transportation
Objective One Assist Ms. Blake with reliable transportation so she can be successful with
treatment.
Task number one Ms. Blake will visit the Secretary States Office to obtain a detailed record of
what she owes on traffic tickets within two weeks.
Task number two Ms. Blake will write a letter to the court magistrate in the cities where she
obtained the tickets to ask for a payment plan within one month.
Task number three Ms. Blake will visit Mother Waddles in Detroit to see if she qualifies for a
donated vehicle within one month.
Objective Two: Ms. Blake will make arrangements to obtain a monthly bus card.

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Task number one Obtain a monthly bus card from the Detroit Department of Transportation.
Task number two Make arrangements for transportation with friends and family members.
Task number three Make prior arrangements for transportation to conduct business and weekly
social work sessions.

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Contract for Intervention Plan

Client Name: Sheila Blake
Description of the Problem:
Ms. Blake needs treatment for her gambling addiction. She also has anger issues
that are interfering with family socialization. She has lost her home and vehicle due
to her gambling. Ms. Blake does not socialize outside the casino. She has poor
financial management skills due to gambling and has to take the bus to and from
work.
Primary Goals:
1. Treatment and intervention for gambling addiction
2. Improve socialization with family members
3. Participate in group sessions for anger management and financial stability
4. Obtain resources to find reliable transportation.
5. Obtain resources to find stable housing.
We the undersigned, agree to the objectives in the following plan:
A. Participate in individual therapy sessions with Social Worker weekly.
B. Participate in group intervention for gambling.
C. Participate in group sessions for anger management.
D. Participate in monthly family therapy.
E. Use online materials for addiction and to obtain resources for housing.
F. Visit charity and nonprofit organizations for assistance with a vehicle.

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X
Signature of Client

Date

X
Signature of Worker

Date