Running Head: BIOPSYCHOSOCIAL ASSESSEMENT

Biopsychosocial Assessment
Bq1441
Wayne State University

BIOPSYCHOSOCIAL ASSESSMENT

Biopsychosocial Assessment
Presenting Problem
Bill Smith (pseudonym) is a 39 year old married Caucasian male who currently lives with
his wife of 15 years and their 18 and 16 year old sons. He is employed as a safety leader for an
automotive company for 3 years. Bill is coming to see a social worker because of amount of
stress he is under at work. He is thankful to have a job after being unemployed for 18 months,
but he is having difficulty adjusting to earning less money. He is trying to receive a raise to
hopefully purchase a new vehicle. His 15 year old vehicle is in constant need of repair. All the
stress and lack of time to eat properly has caused him to gain weight. He is currently taking four
different medications due to health issues that he has been diagnosed with because of his weight
gain.
Family of Origin History
The client stated that his mother was 24 years old and his father was 25 years old at the
time of his planned birth and were married. His parents earned their high school diploma. Bills
father, Robert (pseudonym), has been a builder for over 40 years and his mother, Martha
(pseudonym), has worked as a waitress, but during his childhood she was a homemaker. His
father is now 63 years old and his mother is 62 years old. In 2014, they celebrated 46 years of
marriage.
The client has 3 siblings, all of whom are from his parents marriage. His oldest sister,
Sue, (pseudonym), is 45 years old, and widowed with 2 children. Her husband died of
alcoholism in 2013. She earned her high school diploma and is employed as a receptionist for
local school district. His second oldest sister, Alexis (pseudonym), is 44 years old, divorced with
2 children. She earned her high school diploma and is employed as a sales associate. She

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remarried five years after her divorce. His brother, Tyler, (pseudonym) is 38 years old, divorced
with no children. He earned his GED, attended some college classes, and is employed as a CNC
programmer.
The client has great relationships with all of his siblings. He is closer to his oldest sister,
Sue, because they live in close proximity to each other and she needs him more because she is
grieving the loss of her husband. His second oldest sister, Alexis, recently moved to Alabama so
they cannot see each other as much. The client does side jobs and hangs out with his brother
whenever they can get together.
His family has various health problems. His father suffers from severe arthritis. His mother
has diabetes and high blood pressure. His sister, Sue, has asthma. His sister, Alexis, suffered
from childhood epilepsy. His brother, Tyler, had a motorcycle accident in May 2012 that almost
killed him. Everything was damaged in his body except his head. Since then he has had multiple
surgeries and was finally able to go back to work in November 2013.
The client states that the atmosphere in the home while he was growing up was pleasant.
He has a close relationship with his mother and father. He and his siblings are close in age so
there was always someone there for him. He feels he was raised in a secure happy environment.
The clients extended family lived nearby and always came together for the holidays.
They would meet at his parents, grandparents or aunts and uncles home to celebrated major
holidays such as Christmas, Christmas Eve, Thanksgiving, and Easter. The clients mother was
raised in a Catholic home but did not impose those traditions during the clients childhood. Food
and drink, especially alcohol, were important at these events. A game of Tripoley is always
played while the seasonal sport plays on the television. Christmas included many presents and an
egg hunt for Easter.

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When the death of a person happens, the family all comes together for a funeral and meal.
Sometimes they stay together for days depending upon the person who died. Memories are
shared at the time of death and for years afterward. Sometimes they are shared through tears and
sometimes through laughter.
The client denies any physical or sexual abuse within his family.
Developmental History
The client was a full term healthy baby delivered vaginally. He was 7 pounds 3 ounces at
birth. He was breast fed for the first year of his life. The client believes he met milestones and
did not have any other developmental issues. The client is not aware of advancement in any area
of development.
Health History
The client reports that he was generally healthy during his infancy and childhood. His
only major problem was earaches. For treatment, his doctor would give him a penicillin shot and
prescribe ear drops and pain medication. During childhood he had chicken pox. He did not have
any chronic illnesses and/or serious accidents as a child. He has never broken a bone.
During Bills adulthood he developed health issues. He was an average weight until he
was 18 years old. He began to gain weight gradually and has been unable to maintain a healthy
weight since then. He currently takes naproxen sodium 220mg for arthritis pain, Tenoretic 50
tab for high blood pressure, Prilosec 20.6 mg for acid reflux, and Nuvigil 150mg for sleep apnea.
He had a vasectomy in 2003 because he and his wife decided they did not want any more
children. He has never been hospitalized.
There is no chronic family an illness, except his mother also has high blood pressure and his
father has arthritis, as stated above.

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Relationship/Sexual History
Bill reports he has always had many friends. He stated he likes to be around people a
lot. During his childhood, he was friends with boys and girls. He and his brother are only two
years apart so they spent many days playing sports at the park with the neighborhood kids. He
still talks with many of the people he grew up with and has made new friends in adulthood.
The client is heterosexual. He began dating at 13 years old. His first dates were middle
school girls that he had known since elementary school. Bill reports he had approximately 8
girlfriends before he met the girl who became his wife. Most of the relationships were short
term except for a girl he dated for 1 years. The long term relationship ended when he
discovered she had cheated on him with another male. At 16 years old, he had his first sexual
experience with his 16 year old girlfriend. Even though the experience was initially awkward,
his first time and the times thereafter have been pleasurable. He likes to have orgasms. He
currently has sex 3-4 times a week with his wife. He does not need to use any type of protection
because of his vasectomy. The client states he does not have any sexual transmitted diseases.
Family of Creation History
Bill and his wife, Elaine (pseudonym) had a committed relationship for four years before
they officially got married in 1998 when they were 23 and 22 years old, respectively. They have
now been married for 15 years. While they were dating, they had two boys. The first son,
Trevor (pseudonym) was born in 1995 and is now 18 years old and the second son, Fred
(pseudonym) was born in 1997 and is now 16 years old. The birth of the boys was not planned,
but abortion and/or adoption was not considered when the pregnancy was discovered. Bill and
Elaine moved in together when Elaine was 6 months pregnant and have lived together since then.

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The client states he has good relationships with his family members. The client reports
he and Elaine have a strong relationship. They had been through good and bad times but have
learned to depend upon each other for support. Communication and ensuring they make time for
each other is sometimes difficult but he knows it is important to make sure he finds time to enjoy
his wife. He enjoys hunting and fishing with his boys. He loves to watch them play sports. He
values the time he has with them especially as they get older because he knows they will soon
move out and form their own families.
Bills wife works for the local city and is going to school to complete a masters degree.
His son, Trevor, is a freshman in college. Trevor works for a local city and owns his own wheel
reconditioning business. His son, Fred, also works for a local city and is a high school junior.
Substance Use/Abuse History
Bill tried alcohol when he was 15 years old. He was a social drinker for many years. He
would drink at parties or during the holidays. Sometimes he would drink one beer or mixed drink
other times he would become completely intoxicated. He stopped drinking in 2010 because he
cannot drink alcohol with his sleep apnea medication. The client states that he smoked
cigarettes when he was 16 years old. He smoked approximately one pack a day. He quit
smoking in 2000 when he was 25 years old. Bill reports he tried marijuana when he was 16
years old. He smoked it recreationally for about 10 years. He smoked it with friends at parties.
The client no longer smokes marijuana and cannot remember the last time he tried it.
The client reports he does not have an eating or gambling addiction. He never sought
treatment for any of his substance uses. When he decided he wanted to quit, he did.

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Mental Health History

The client denies any mental health history.
Military History
The client denies any military history.
Financial History
The client reports that while he was growing up there were times when they had all their
needs met plus some of their wants and other times when having food in the house was difficult.
Since his fathers job as a builder was seasonal in Michigan and the economy would greatly
affect available work, finances varied. Due to the variation, he was not taught how to manage
his money well. As an adult, he was able to have steady employment and be financially secure
until his 18 months lay off that started in 2009. As a result, he and his wife had to file
bankruptcy and agree to a short sale on their home. Currently he is getting back on track and has
decided to no longer use credit cards.
Legal History
The client denies any legal problems.

Immigration Issues
The clients family came to the United States through Jamestown in the 1600s. He
denies any immigration issues.
Religious History
The client stated that during his childhood, his mother taught them a little about the
Catholic religion and his great uncle would take him to a Baptist church on Sundays and
Wednesdays. He reported that he thought church was fun as a child. As an adult, he attended a

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Pentecostal church with his wife. Eventually they decided to attend a non- denominational
Christian church where he is now a member. He has participated with many outreach programs
like free oil change day and a homeless assistance program. He also assists the deacons and
pastor in fulfilling practical needs of other members and attendees. He denies any issue with
religion or spirituality.
Educational History
The client attended elementary, middle, and high school. He did not receive any special
education and sometimes made the honor roll. He earned his high school diploma in 1993. In
1995, he attended Motech. Motech is a trade school that provided automotive mechanic classes.
He completed most of the classes but dropped out at the end. He took the mechanics test at the
Department of Motor Vehicles and received his license in several specific fields (i.e. brakes,
engines, electrical). Bill knows he understands subject matter better when it is taught through
hands on learning versus just reading about it. He is currently not interested in continuing his
education.
Employment History
Bill reports that he and his siblings had to complete all kinds of chores at home. At times
he was required to do household chores like cleaning the bathroom and washing the dishes other
times he had to split wood for the wood burning stove or mow the lawn.
The client stated working with his great uncle at 12 year old roofing houses during the
summer. He worked at various fast food establishments in his late teens, but once he became a
car porter at a dealership when he was 18 years old, he rarely work in any other field. In 1995,
he worked as a mechanic at Tuffys, then moved to JR Spring and Tire in 1996, and then to
Oakland Tire 1997. In 2000, he was took a job as a fleet mechanic of a local potato chip

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company. In 2009, he was laid off from that job so the company could hire two people for what
they had been paying him. In 2011, Bill started working as a safety leader at a local automotive
testing company where he is still currently employed. Until his lay off, he only changed jobs
because of an increase in income and opportunity. His current job started him off at substantially
less than what he was being paid but he needed a job. Since his date of hire, he has received
many wage increases, but is still not receiving as much as he was in 2001. His current benefits
are an annual pay of $50,000-$55,000, medical insurance for he and his family, 401K, and 2
weeks vacation. He considers his pay average compared to similarly educated people. Bill loves
to work on vehicles. The client reports he does not like some of the additional stresses from
engineers who do not understand an actual vehicle that is not on a computer screen. Overall, he
does enjoy working on vehicles and does not know what else he would rather do.
Strengths
The client presented many support systems during our meeting. He has a great
relationship with his supportive wife and children. His parents, siblings, and extended family are
interested in his wellbeing. His wifes family provides additional support.

His church friends

are there when needed. These groups of people were very important to him especially during his
18 months of unemployment. The client is surrounded by many friends.
Even though his job may stress him, he has formed many friendships with his coworkers.
His job evaluation states he is a useful employee that works well with others. He maintains a
strong work ethic.
The client has the ability to be observant of his surroundings and naturally is interested in
the protection and well-being of others whether he knows them or not. He will stop and help
people on the side of the road or help a person with their groceries at the store.

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Family and friends are extremely important to Bill. He spends time insuring his children
know the importance of them also through helping shoveling snow for a neighbor and/or
attending all the family gatherings. Bills desire to serve them provides him a sense of
accomplishment.
Bills maintains his hygiene and is in fair physical condition. He is friendly and willing
to seek help.

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Step 1: Working with the client

Bill revealed some issues that he is battling currently. He would like to address these issues and
build a plan of action. The client defines the issues listed below:
Issues:
1. The client is dealing with stress at work caused by poor communication.
2. Bill needs to earn more money to purchase a newer vehicle.
3. Bill would like to lose weight so he can be healthier and not have to take so much
medication.
Step 2: Prioritize the Problem:
1. Stressful work environment
2. Needs to lose weight
3. Needs extra money

Step 3: Translate the Problem into Need

Problem

Need

1. He has a stressful work environment

1. Reduce stress at work.

2. He is overweight.

2. Lose weight

3. He needs money to purchase a car

3. Earn extra income.

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Step 4: Evaluate Levels of Intervention for Each Need

Need #1: Reduce stress at work
Micro Strategy: Find a book or pamphlet about relaxing breathing techniques at the local library.
Pros:

He can learn ways to breathe properly and calm himself down.

The resource should be free.

Cons:

He may not be able to find the book or pamphlet in the library.

He may need more than breathing techniques to calm down.

Mezzo Strategy: Talk with coworkers about changing methods at work to reduce stress
Pros:

He could discover ways to getting along with his coworkers and reduce his stress.

They could all create something that would reduce stress for them all.

Cons:

The coworkers could be uncooperative with the whole idea.

Bills stress may increase by trying to create a new plan with his coworkers.

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Macro Strategy: Speak with his supervisors about ways to decrease stress in his place of
employment.
Pros:

His supervisors may create a new plan of dealing with communication issues to reduce
stress.

The new plan will reduce Bills stress.

Cons:

His supervisors could do nothing.

His conversation with his supervisors could cause more stress.

Need #2: Lose Weight

Micro Strategy: Consult doctor for nutritional information and individual diet plan.
Pros:

He could discover some good tasting meal ideas.

He could lose weight.

He would be supervised by a medical professional to adjust his medication if necessary.

Cons:

He may not be able to find meals he would like to eat.

He may find it difficult to change his eating habits.

Seeking help from his doctor may be expensive.

Mezzo Strategy: Join a weight loss group.

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Pros:

Working with others that are trying to lose weight may help him.

There are several groups available in his area.

Cons:

He may not relate well to the other group members.

The meeting fees may be costly.

He may miss out on overtime at work to go to meetings.

Macro Strategy: Macro Strategy is not available for weight loss .

Need #3: Find extra income
Micro Strategy: Talk to supervisor about a raise at current employment
Pros:

Supervisor may agree to increase wages.

Bill would have more money.

Cons:

The supervisor could deny raise.

The raise may require more work responsible that could cause more stress.

Mezzo Strategy: Find or create a group to carpool to save in fuel and repair cost.
Pros:

Bill may save a lot of money in fuel cost if he could arrange a carpool with others.

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If Bill did not have to drive his vehicle every day, it may last longer so he can save
more money.

Cons:

He would have to depend on others to get to work.

He may not have anyone that he could carpool with.

Macro Strategy: Macro strategy does not apply because Bill would not qualify for assist from a
needs-based organization.
Goals, Objectives, and Tasks
Goal #1 Reduce Stress at Work.
A. The client will find a pamphlet or book about breathing techniques.
1. Find local library within three days
2. Visit library to inquire if book or pamphlet is available within five days.
3. Purchase book or pamphlet at a bookstore if he is unable to locate one at the
library within 7 days.
4. The client will look over the book or pamphlet and try the techniques within
the fourteen days.
B. Communicate with coworkers about work environment.
1. Talk with coworkers about having a meeting within three days.
2. Host a meeting within seven days.
3. Implement new ideas within fourteen days.

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C. Seek assistance from work supervisors.

1. Request meeting with supervisor within three days.
2. Attend meeting within seven days.
3. Introduce new plan suggested by supervisor within fourteen days.
Goal #2 Bill will lose weight.
A. Consult his doctor for assistance in weight loss
1. Bill will make an appointment with his doctor within two days.
2. He will attend the appointment within seven days.
3. The client will follow the plan suggested by the doctor within ten days.
B. Mr. Smith will attend weight loss group meetings.
1. Bill will select a local weight loss group from a resource list provided to him
and call the organization to inquire about meeting dates and times within five
days.
2. The client will attend the weight loss group within the following fourteen
days.
Goal #3 The client will find a way to earn extra money.
A. Bill will seek extra income with his current employer.
1. Bill will request a meeting with his supervisor within seven days.
2. Bill will attend the meeting and request an increase in his pay rate within
fourteen days.
B. Bill will locate or create a carpool group.

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1. The client will attempt to find a local carpool group by talking with coworkers
with five days.
2. If a group is found he will join it within ten days.
3. If he cannot find a group, he will create his own within fourteen days.
4. Bill will put aside the money he was previously spending on gas to purchase a
newer vehicle within one year.

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Contract for Intervention Plan

Client Name: Bill Smith (Pseudonym)
Description of Problem:
Mr. Smith needs to discover ways to reduce stress in his life especially in his work environment.
He would like to lose weight to enable him to live a healthier life. He is also in need of extra
income to purchase a more reliable vehicle.
Primary Goals:
1. Reduce stress at work.
2. Eat healthier and lose weight.
3. Find ways to earn additional income.
We, the undersigned, agree to the objectives in the following plan:
A. Incorporate relaxing breathing techniques learned from book or pamphlet within two
weeks.
B. Communicate with coworkers and supervisors about ways to improve work environment
stress with three days.
C. Start personal weight loss plan suggested by doctor within ten days.
D. Attend a weight loss group to receive additional support within one month.
E. Request a raise from employer within fourteen days.
F. Carpool to work within fourteen days.

Signature of Client

Signature of Worker

Date

Date

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