Running head: BIO-PSYCHO-SOCIAL ASSESSMENT PART A & B

Bio-Psycho-Social Assessment Part A & B

Keely Sopko
FN 8459 / SW 3020
7-10-15

BIO-PSYCHO-SOCIAL ASSESSMENT PART A & B

Demographic Information
Name: Brenda Hollis

Date of Birth: 3/31/1972

Address: 111 N. Suncrest St.

Age: 43 years old

Flint, MI

Sex: Female

Phone: (616) 231-1325

Ethnicity: African American

Intake Clinician: Keely Sopko

Date of Interview: 7/13/15

Presenting Problem

Brenda Hollis (pseudonym) is a forty-three-year-old African American female. She was

widowed two years ago by Anthony (pseudonym), her only husband and the father of her two
children (two males, ages twenty-three and twenty-five years old). She currently lives with her
sister named Sherry (pseudonym). Brenda is currently unemployed and has not worked since her
husband passed away. Brenda has been drinking alcohol daily. She is coming to see a social
worker because of the grief she feels over losing her husband. Additionally, she has experienced
the grief of losing her sons to their independence. She claims that the alcohol is not numbing her
anymore, and she is feeling very depressed but not suicidal. She and her sister, Sherry also
struggle with their relationship. Brenda states that Sherry is always telling her what to do, like
she is her boss. Although, Brenda finished high school she always struggled with school. She
claims to take longer than everyone else at grasping concepts related to her education. She never
wanted to go to college because she barely made it through high school. Brenda also claims to
struggle continually with math, reading, and writing. Prior employment for Brenda has been
sparse throughout the years. She has had various minimum wage jobs but nothing that she ever
enjoyed. She always complained about them not being right for her. Brenda complains that she
is feeling hopeless and that there is not a place in the world for her.

BIO-PSYCHO-SOCIAL ASSESSMENT PART A & B

Family of Origin History

Brenda was born to Oliver Matthew (pseudonym) (age twenty-one) and Beatrice Farmer
(pseudonym) (age twenty) on March 31, 1972. Oliver and Beatrice were not married when
Brenda was born but tied the knot shortly after her birth. Oliver was an assembly line worker at
Ford Motor Company. Beatrice was unemployed and ended up dropping out of high school to
give birth to Sherry. Oliver and Beatrice planned Sherrys pregnancy. However, the two of
them did not plan Brendas birth. Although Brendas dad graduated high school, neither he nor
Brendas mom ever went to college. Oliver and Beatrice had three other children. Brenda was
the second of four children. Sherry was the oldest and was born in 1970. Brenda has one
younger sister (Ann, age forty) (pseudonym), and a younger brother (Steven, age thirty-seven)
(pseudonym). Sherry is divorced and currently employed at Chase Bank as a manager. Brenda
never has had money in savings, while married her and husband struggled with saving money.
Ann works at a local community college as a professor. She has three children and is married.
Steven is single and is a small business owner. Both of Brendas parents have passed away.
Oliver passed away ten years ago from a massive heart attack at work. Brendas mom, Beatrice
died eight months later from undetected and undiagnosed cervical cancer. Both of their deaths
took a toll on the relationships between their children. Both Oliver and Beatrice passed away
very unexpectedly leaving the family with costly funeral expenses and no time for preparation.
Sherry and Ann took care of the funeral arrangements for both parents. Steven had just started
his business and was struggling to keep it afloat. All four of the children struggled with grieving
over their parents. Sherry and Ann addressed their feelings by staying busy and neglecting to
face them. Steven was extremely distraught and almost lost his business because of his lack of

BIO-PSYCHO-SOCIAL ASSESSMENT PART A & B

attendance at his newly opened shop. Brenda began to drink pretty heavily following her parents
death but quit shortly after because her husband did not approve and threatened divorce.
The atmosphere, when Brenda was growing up, was somewhat common for people in her
neighborhood. He father worked all of the time, and their mother was their primary caregiver.
She grew up in a strong patriarchal household. Brendas oldest sister Sherry was the shining star
of the family. She always excelled in school, and if their mother was absent, Sherry took on the
caregiver role. Additionally, she attended college and was extremely successful in her line of
work. Ann also did well in school and attended a college where she eventually achieved her
masters degree in education. Steven attended to barber school and currently owns a barber
shop. Brenda never went to college, she got married and had children at a young age, and there
was no time to spend on becoming educated. She always believed it was a waste of time to go to
school after high school. All of Brendas siblings are in good health. Brenda has struggled with
high blood pressure and strain to her liver from drinking. When Steven was an infant, he was
born with a congenital heart defect. However, it has had little to no effect on his life because it
was minor and did not require any treatment.
Extended family members usually spent the holidays at Beatrices and Olivers home.
There was always a lot of people, food, and gifts at these holiday parties. During the holidays,
family members attended a mass led by Reverend Everett Green (pseudonym) at the Baptist
Church in their town. All of the family wore their best clothing for holiday mass. Many of the
extended family members lived nearby, and all of them, including Oliver and Beatrice attended
mass regularly with their children. Although, there are no signs of current abuse; it was normal
for their father to whip their butts with a razor strap when they were younger if they misbehaved.

BIO-PSYCHO-SOCIAL ASSESSMENT PART A & B

Developmental History
Brenda was born one month early. Her mother struggled through all of her pregnancies.
The struggle may have resulted from her young age while pregnant. Brenda was born in a Csection because doctors discovered she was a breach baby. She weighed five pounds three
ounces. There were no other medical issues regarding her birth. Brenda was bottle fed. Her
mother chose to bottle feed her because she claimed that it was easier to do it this way with
Sherry being a toddler. Although there were no medical issues present at Brendas birth, she did
not walk until she was fifteen months old. Beatrice claimed that Brenda was a late bloomer. She
took a long time to walk, talk, and potty train. She began talking at approximately age two and
did not potty train until she was almost four years old. However, Brendas doctor never
diagnosed her with a developmental delay.
Health History
Brendas health at birth was acceptable. She was born small in comparison to her
siblings. However, the doctors never diagnosed her with any health issues following her birth.
Brenda had the chicken pox when she was seven years old. When she was sixteen years old, she
was in a car accident, and the doctor determined that she suffered a closed head injury.
Additionally, she had surgery on her knee right before her husbands passing. She had issues
with it for many years prior to surgery. Since the surgery, she has not had any problems with it.
Currently, she has high blood pressure and strain on her liver from drinking alcohol. Brenda
weighs one-hundred eighty pounds and is five foot four inches tall. Her weight seems to
contribute to her high blood pressure as well. Recently, the doctor told her she needs to get more
exercise to drop a few pounds and possibly lower her blood pressure. She is currently on blood
pressure medication. She is allergic to penicillin. Her first menses began at ten years of age.

BIO-PSYCHO-SOCIAL ASSESSMENT PART A & B

Relationship/Sexual History
When Brenda was growing up, she only had one close friend. The neighbor named
Renee (pseudonym) is still Brendas nearest and dearest friend. She has been there for Brenda
since they were five years old. She attends the same church as Brendas family. She was there
when Brendas mother, father, and husband passed. However, Renee's daughter was arrested
and jailed as a result of drunk driving. She is currently very busy raising her granddaughter.
Brenda became sexually active at eleven years old. She met her husband when she was fifteen
and did not have any other sexual relationships with anyone other than him until after his death.
Following the death of her husband, she has been practicing unsafe sex with multiple partners.
Although, she reports being sexually active, she states that she does not enjoy sex and is unable
to achieve orgasms. She also states that her current sexual relationships are nothing compared to
what she had with her husband. She says that she is not on birth control and does not worry
about getting pregnant because she had a tubal litigation after the birth of her second son.
Family of Creation History
Brenda was eighteen years old when she married Anthony. She was pregnant with her
first son, and this was the reason for their marriage. Anthony was much older than Brenda. He
was twenty-five when they married. He attended a two-year community college where he
obtained a degree in automobile mechanics. He passed away when he was forty-eight years old.
Brenda and Anthonys children were Anthony Jr. (pseudonym) (twenty-five years old) and
Benjamin (pseudonym) (twenty-three years old). Brenda never had any other children,
miscarriages, or abortions. Both Anthony Jr. and Benjamin were planned pregnancies. Brenda
secretly hoped for a daughter but knew they could not afford any more than two children on her
husbands income. Brenda wanted to have children at a young age because she thought she

BIO-PSYCHO-SOCIAL ASSESSMENT PART A & B

would have a purpose and live a more meaningful life. Brenda describes her time with Anthony
as the best days of her life. She explained that he could have a bit of a temper, but she refrained
from making him upset because it was easier that way. Anthony did not like Brenda working.
He thought that he should be the sole provider of their household. Brenda claims that is another
reason as to why she never stayed at a job very long. Brenda states that both of her sons were
very close to their dad. Although, Brenda was the primary caregiver, Anthony Sr. helped the
boys with their school work and played ball with them outside as they were growing up. Brenda
feels as though her relationship with her sons is strained. They do not come around very much,
and this started a couple of years ago when she began drinking. Anthony Jr. just got involved in
a serious relationship with a girl who has a little boy. Prior to this relationship Anthony Jr. has
one daughter but none of the family ever sees her because her mother moved away when the
baby was first born. They had the baby when they were both still in high school. Anthony Jr.
and his new girlfriend recently moved in together, and Brenda thinks this is the reason that he
has not been around as much. Benjamin lives farther away and only comes to visit during
holidays. He is single and never has been married or had any children. There are no signs of
abuse in any of the current relationships. However, Anthony Jr. struggled in high school with his
daughters mother. They were constantly fighting and engaging in domestic abuse.
Substance Use/Abuse History
Brenda has struggled with drinking alcohol in the past and currently. Now is the worst
she has ever been according to her sister. In her early teenage years and following the birth of
both of her sons she used alcohol excessively. She claimed that she used alcohol after the birth
of her sons to battle off the baby blues. However, she has never had a problem putting down the
alcohol until now. She claims that she had always been able to quit drinking when she wanted

BIO-PSYCHO-SOCIAL ASSESSMENT PART A & B

to, but this time is different. Now when she tried to quit, she gets very anxious and shaky. She
first used alcohol when she was twelve years old. She began smoking cigarettes when she was
sixteen years old and has smoked ever since. Anthony Sr. also smoked cigarettes. The doctors
who treated Anthony Sr. when he passed away said that smoking cigarettes were one of the main
factors that led to his death. Brenda states that she has drunk a twelve pack of beer today and
does not feel buzzed at all. Brenda also states that she has a love for food. Since her husbands
passing, she has put on twenty-five pounds. She says this is a result of her horrible eating habits.
She claims to enjoy spicy deep fried hot wings and anything sweet, like candy. Brenda never
sought out treatment for her alcohol use.
Mental Health History
Brenda has only seen one mental health doctor. Her visit to him occurred right after her
husbands passing. She sought out the doctor on her own because she was so upset about her
husbands untimely death. The doctor diagnosed her with depression. He gave her medications,
and she took them for about a month and then discontinued them. She claimed they did not help
her at all. According to Brenda, the alcohol worked better. Sherry told Brenda she might not
drink as much as she does if she continued to see the doctor. Sherry and Ann are both fed up
with Brendas juvenile shenanigans. They want to see her get the help she needs by quitting
drinking and following up with the mental health doctor.
History of Other Issues
Brenda has never been in the military. Additionally, she has never had any legal troubles.
Brenda and her husband struggled financially to survive and support their children on one
income. Although, she collects survivor social security, she has no other income. Brenda never
has had money in savings, while married her and husband struggled with saving money. Sherry

BIO-PSYCHO-SOCIAL ASSESSMENT PART A & B

took her in because she could not allow her sister to become homeless. After the death of her
husband, Brenda was forced to sell their home because she could not afford it. She did not make
any money on the sale; the market was down, and the home needed a lot of repairs. When
Brenda was growing up, she does not remember her family struggling with finances at all. She
says they had everything they needed. Additionally, Brenda has no immigration issues; she has
been a U.S. citizen her whole life. She has been attending church regularly her whole life. She
attends the same Baptist church she went to as a child. The clients strengths include her sisters
deep care for her, her church attendance, her close friend Renee, and her ability to function well
when feeling needed.
Mental Status Exam
Brenda dressed inappropriately for the interview. Her appearance was quite messy, and
there were stains on her clothing. She was oriented (times three), by time, place, and person
(Neukrug & Schwitzer, 2006, p. 317). She presented with a low mood, under the influence of
alcohol, and her affect was depressed (Neukrug & Schwitzer, p. 317). She was slow in giving
responses to the social worker because of her current state of being under the influence. She did
not report any hallucinations. However, she did report suicidal thoughts with no plan to carry
through. Brenda appeared to below average intellectually, and she struggled with memory
retention (Neukrug & Schwitzer, p. 317). Her insight was extremely low, and she presented with
very poor judgment (Neukrug & Schwitzer, p. 317). She did not appear motivated for treatment.
Although she reports, she currently feels she has no purpose, she does not seem to be harmful
to herself or others, other than drinking daily (Neukrug & Schwitzer, p. 317).

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Assessment
Brenda reported that her major concern was her struggling relationship with her sister,
Sherry. She informed the social worker that Sherry insisted that she come to the appointment
today. Brenda also informed the social worker that Sherry is always getting upset with her for
drinking so much. She has even threatened to kick Brenda out of her home, but still Brenda
believes her drinking is not the problem. She believes that it is her sisters problem, and if she
minded her own business, there would not be any issues. However, she does report being
extremely unhappy and wanting to learn more efficient ways to cope with her husbands death.
Additionally, she reports that her sister may be right because she has always had her best interest
at heart. On a Beck Depressed Inventory (BDI), she identified her major problems as her
relationship with her sister and improperly grieving the loss of her husband (Neukrug &
Schwitzer, 2006, p. 317). These present as Brendas most critical problems (Kirst-Ashman &
Hull, 2012, p. 39). On the BDI, Brenda scored a high range of depression.
The worker establishes that Brenda does not feel good about herself. The worker will
explore resources available that will assist Brenda in feeling better about herself. Additionally,
the social worker will examine the relationship between Brenda and Sherry more extensively. It
may be possible to invite Sherry to join them in sessions. The worker will suggest that Brenda
reach out to Renee for support since they have been friends for so long. Another strength lies
within Brendas church. Brenda may be able to seek support service through them as well.
Summary and Conclusions
Brenda is a forty-three-year-old alcoholic who is grieving the loss of her husband and is
struggling in her relationship with her sister. She is currently unemployed and not attending any
educational programs. She is co-occurring in the aspect that she not only suffers from

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11

alcoholism but depression as well. Her primary goal is to learn more efficient ways to cope with
the loss of her husband and to better her current relationship with her sister. She appears to be
open to exploring the treatments that will reduce her depressed feelings although she does not yet
see her alcohol use as a problem. The social worker has explored many avenues to see if there is
help for Brenda on micro, mezzo, and macro levels. The social worker found a support group at
Brendas church for grieving and loss. The social worker was also able to locate a family group
at their church as well. This group focuses on family problems and issues.
Treatment Plan
I.

Goal number one: Brenda will increase her ability to cope with her husbands death.
A) Objective number one: Brenda will report that she talked about her feelings of loss,
with a friend, support group, or family member at least three times over the next
month.
1) Task number one: Brenda will attend a support group at her church for grieving
and loss at least twice a month for six months.
2) Task number two: Brenda will reach out and call Renee at least twice a month.
B) Objective number two: Brenda will explore other avenues to learn how to cope
effectively with the loss of her husband.
1) Task number one: Brenda will write in a journal about her feelings daily for one
month.
2) Task number two: Brenda will share her journal thoughts with her therapist so
they can effectively address those feelings once a week.

II.

Goal number two: Brenda will improve her relationship with her sister by exercising
attentive listening skills with her sister.

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A) Objective number one: Brenda will report that she listened to her sister at least twice
a month over the next six months.
1) Task number one: Brenda and her sister will attend family counseling once every
other week for the next six months.
2) Task number two: Brenda and her sister will attend the family group at their
church once a month for six months.
B) Objective number two: Brenda will explore other areas that may improve her
relationship with her sister.
1) Task number one: Brenda will reflect on what her and Sherrys relationship used
to be like and write about it once a week for one month.
2) Task number two: Brenda will share those thoughts with her therapist once a
week for a month.

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References
Kirst-Ashman, K., & Hull, G. (2012). Understanding generalist practice (6th ed., p. 39).
Belmont, CA: Brooks/Cole/Cengage Learning.
Neukrug, E., & Schwitzer, A. (2006). Skills and tools for today's counselors and
psychotherapists: From natural helping to professional counseling (p. 317). Southbank,
Vic.: Thomson/Brooks/Cole.