Bio-Psycho-Social Assessment

Bio-Psycho-Social Assessment SW 3020 March 21, 2013 Brian Meadows Wayne State University

Bio-Psycho-Social Assessment

Presenting Problem Ann Bailey (Pseudonym) is a 56 year old, single African American female who has been single for 7 months and living in transitional housing provided by a rehab center, Quality Behavioral Health, where she is a recovering drug addict. She currently works for QBH as a driver, transporting clients to take care of personal matters. Ms. Bailey is coming to see a social worker due to the stress she is experiencing from her transition back into every day life, trying to secure stable housing, employment, and to sever connections to her past drug use. Family of Origin History The clients mother, Willie Bailey, was 37 when she gave birth to the client. The father, Willard Bailey, was 42 when the client was born. The parents were married when the client was born. The client was an only child. The mothers pregnancy was planned. She was previously pregnant twice, but miscarried both times. The clients parents separated due to the fathers drinking problem. The clients father died of tuberculosis at the age of 64. The clients mother died of heart failure and diabetes at the age of 81. The client states that she had a pleasant childhood and was in a happy environment. She had what she needed and was cared for. Family holidays were family affairs. The family would gather at the clients house, have dinner, and enjoy invaluable family time and interaction. The clients father completed high school, while the clients mother only completed the eighth grade. The client stated that death was handled well in the family. She learned about death and how to handle it from her mother and aunt, who let her know that people often times die when they get older and/or their body just cant function anymore. The client really didnt have to deal with a death close to her until her early 20s, when her father passed away. The client was never abused as a child in any way.

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Developmental History The clients mother gave birth after 9 months of pregnancy. The client states that she was 6 pounds, 9 ounces at the time of birth, via information from her birth certificate. There were no issues present at the time of the clients birth. The clients mother had a vaginal birth and bottle fed the client. The client does not remember being told when she was weaned from bottle feeding. Client states that she learned to walk between 10 to 12 months, talked around 6 months and was potty trained around a year and a half. The client was never told that she was advanced developmentally or had developmental delays. Health History The client states she was healthy at birth. The only childhood illnesses she remembers having are colds and the flu. She was nine and a half years old when she had her first menses. The client currently suffers from heart disease and hypertension. She has suffered two heart attacks and had stent surgery after the second heart attack. The client is currently taking Hydrochlorothiazide, Metoprol, Norvasc, and Bayer aspirin for her medical conditions. The client states that her family has been healthy for the most part during her life. Relationship/Sexual History Important childhood friendships include Lydia, who she has known since 14 years of age, Vanessa, known since 10 years of age, and John, known since 12 years of age. The client states that these were happy and enjoyable friendships. The clients current friendships include Terry and Beverly, who she has known for about 2 years. She also keeps in contact with Lydia and John. The client is heterosexual and began dating at 14 years old. She had her first sexual

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experience and is able to have normal sexual experiences. The client is currently not in a sexual relationship, and has never contracted STDs. Family of Creation History The client has been in several committed relationships. She was married to Anthony for five years, with Marc for seven years, and cohabitating with Weldon for two. The client was 22 years old when she began dating Weldon, 28 years old when she married Anthony and 48 when she began dating Marc. The client got married because they were in love and cared for one another. She had one child, Alexander Bailey, who is now 22 years old. The client was satisfied in all her relationships, except Marc. The clients relationship with Marc went back and forth, as he contributed to her drug issues, which led to the breakup. She divorced Anthony because they grew apart and didnt get along. The client states that the relationship with Weldon was mutual, and theyre friends currently. She has a good relationship with her son, who is currently unemployed, but is in college. The client had an abortion and miscarriage before having her son. She states that the first two pregnancies were accidental, but the third was planned because she pretty much knew she was going to end up pregnant. The client had a child because she was in love with the childs father. The clients current relationship with her son is better than ever. She states that it was tense because her son didnt like her lifestyle choices but he never gave up on her. The client is clean and her son is extremely proud of her. Substance Use/Abuse History The client has used, abused and been addicted to cocaine. Her first use of cocaine was at the age of 26, and the last time she used cocaine was June of 2012. The client doesnt remember how much cocaine she used last. She has been an avid smoker from the age of 25 to present. She says

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stress is the reason for her smoking and cocaine addictions, and she has been in treatment three times. The first two times failed because she went back to the people and environment where her drug problems started. The third time has been a success and she has been clean for 7 months. The client states that a reality check from her son helped her stick to it this time. Mental Health History The client suffered from depression and couldnt function from day to day as she felt that things werent getting better in her life. She felt that no matter what she did, things were just going to turn out bad. Treatments were received at the same facility where she participated in drug rehab. She was prescribed Lexapro for depression and treatment has been successful evidenced by a more positive outlook on life. Military History The client has no military history. Financial History The client states that the finances while she was growing up were good. The clients mother and father worked; the mother for the railroad and the father in textiles. The client currently receives social security and an income from her job as a driver for QBH. Legal History The client has no legal history. Immigration History The client has no immigration issues.

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Religious History The client states that religion/spirituality was strong in the family. The clients family is Christian/Baptist and religion/spirituality is very important to the client and her family. They believe in family, love for one another and helping whenever necessary. The client was very active in church participating in the choir, playing the piano during service and being an usher. While the client hasnt been to church in sometime, she still holds the same beliefs and has no issue with them. Educational History The client attended Detroit Public Schools from kindergarten to the 12th grade. She received her Bachelors Degree in Secondary Education from Wayne State University. The client feels that she is very intelligent, despite the decisions she has made. The client wants to pursue her Masters Degree in the near future. Employment History As a child, the client had chores at home including vacuuming, dusting, and washing dishes. The client worked as a Student Assistant at Wayne State from 1972-1974, a Unit Secretary at Hutzel Hospital from 1976-1978, a substitute teacher for Ecorse Public Schools from 1980-1982, and a Substitute/Contract Teacher for Detroit Public Schools from 1982-2006. The client enjoyed these jobs while she held them. She switched jobs for better pay and advancement in the career she really wanted to pursue. The client made about $30,000 a year and feels that the pay is consistent with her training. Strengths

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The client is committed to doing the right thing after experiencing difficult times in her life and shes dedicated to making things work for the better. Shes very intelligent and optimistic about the future and wants to achieve her goals. The client is good with kids, loves teaching and has great reading and vocabulary skills. She has a strong support system that includes her family and friends, people who love her and want to help her succeed. Plan of Change Step 1: Work with the client. Step 2: Prioritize problems. 1. Transition after rehab 2. Housing and education 3. Severing ties to her past drug use Step 3: Transition problems into needs. 1. Counseling and/or group sessions 2. Assistance for low income housing and education 3. Constructive activity and positive people to socialize with Step 4: Evaluate levels of intervention for each need. 1. Micro: Counseling; Pros & Cons: Helps client deal with stress; Strengths: Determination. Mezzo: Support Groups; Pros & Cons: Having help from others going through the same thing; Strengths: Commitment.

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Macro: Advocating for more programs to help individuals transition into everyday life after rehab; Pros & Cons: More options for individuals out of rehab; Strengths: Intelligent and helpful. 2. Micro: DHS worker; Pros & Cons: Provides options for client to take; Strengths: Receptive to advice and assistance. Mezzo: Support Groups; Pros & Cons: Helps one another with each step of securing housing and educational opportunities; Strengths: Works well with others. Macro: Advocate for housing that client can afford based off income; Pros & Cons: Eliminates stress; Strengths: Confidence. 3. Micro: Plans out life plans with worker; Pros & Cons: Helps client prioritize; Strengths: Organization. Mezzo: Group outings; Pros & Cons: Participating in positive activities; Strengths: Positive self-image. Macro: Advocate for more groups that focus on progress; Pros & Cons: Helps reinforce positive feelings and thoughts; Strengths: Building self-esteem. Goals, Objectives and Tasks 1. Ms. Bailey will increase her self-confidence. A. Ms. Bailey will record daily positives. 1. Ms. Bailey will buy a journal. 2. Ms. Bailey will only record positive feelings and thoughts in the journal each day. 3. Ms. Bailey will report each week to discuss recordings. B. Ms. Bailey will prioritize her life. 1. Ms. Bailey will find and call a life coach within 1 week.

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2. Ms. Bailey will schedule an appointment with the life coach within 2 weeks. 3. Ms. Bailey will attend appointment with life coach within 3 weeks. 2. Ms. Bailey will begin to stabilize her life. A. Ms. Bailey will begin searching for housing. 1. Ms. Bailey will find options for Low Income Housing within 1 week. 2. Ms. Bailey will schedule an appointment at a potential residence within 2 weeks. 3. Ms. Bailey will attend appointment within 3 weeks. B. Ms. Bailey will start the process of going back to school. 1. Ms. Bailey will fill out a college/university application within 1 week. 2. Ms. Bailey will apply for financial aid within 2 weeks after being accepted. 3. Ms. Bailey will register for classes and a tutor within 2 weeks of being awarded financial aid. 3. Ms. Bailey will develop, repair, and maintain positive relationships. A. Ms. Bailey will attend outpatient group sessions. 1. Ms. Bailey will attend group sessions each week. 2. Ms. Bailey will set up outings with group members each week. 3. Ms. Bailey will report in person each week with group attendance sheet and to discuss what she did with her friends. B. Ms. Bailey will spend more time with her family. 1. Ms. Bailey will go out with her family once a week. 2. Ms. Bailey will attend church with family each week. 3. Ms. Bailey will talk to a family member each day by phone or in person.

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Contract for Intervention Plan Client Name: Ann Bailey 1. Description of the Problem: Ms. Bailey is a recovering drug addict who wants to put her life back together. She is having trouble transitioning into everyday life, securing housing, employment, and severing ties to her past rug use. 2. Primary Goals: Ms. Bailey will increase her self-confidence, stabilize her life and develop, maintain, and repair positive relationships. 3. We, the undersigned, agree to the objectives in the following plan: A. Ms. Bailey will record daily positives B. Ms. Bailey will prioritize her life C. Ms. Bailey will begin searching for housing D. Ms. Bailey will start the process of going back to school E. Ms. Bailey will attend outpatient group sessions F. Ms. Bailey will spend more time with her family

(Signature of Client)

(Signature of Worker)

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