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Biopsychosocial Assessment

Bq1441

Wayne State University

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. Bill’s 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 parent’s 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 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 client’s 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 client’s mother was raised in a Catholic home but did not impose those traditions during the client’s 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.

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 Bill’s 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.

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 ½ 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.

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.

Bill’s wife works for the local city and is going to school to complete a master’s 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.

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 father’s 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 client’s family came to the United States through Jamestown in the 1600’s. 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 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 Tuffy’s, 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 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 wife’s 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.

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. Bill’s desire to serve them provides him a sense of accomplishment.

Bill’s maintains his hygiene and is in fair physical condition. He is friendly and willing to seek help.

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.

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.

• Bill’s stress may increase by trying to create a new plan with his coworkers.

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 Bill’s 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.

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.

• 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.

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.

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.

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 Date

Signature of Worker Date

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