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Bio-Psycho-Social Assessment

Bio-Psycho-Social Assessment

Sample Answer 

Bio-Psycho-Social Assessment

Part A

Name: Dalia

Date: 30th January 2020

Agency: Private Family Counselor


Age: 14 years

Ethnicity: Bi-Racial (African and Irish American)

Marital Status: Single

Date of Birth: 2006


Client Self-Assessment of Problem(s)/Reason(s) for Seeking Treatment/Motivation Onset/Duration/Intensity/Frequency Precipitating Stressors/Stressful Events Symptoms (in Client’s/Informant’s Own Words)

Dalia’s parents reported a change in behavior in their daughter. The parents also reported that Dalia sleeps most of the day and is awake most of the night. They also reported that she is highly impulsive and has a highly irritable mood. The client admits to taking alcohol with friends despite her young age. She stated that she believes that participating in extracurricular activities is boring and corny, a sign of disinterest. Additionally, Dalia is physically threatening and argumentative at home. She is argumentative with authorities in school, verbally combative when confronted, and gets into physical fights with her peers. She also misses school on some days (truancy) and exhibits poor concentration in school. Further, Dalia is highly sexualized with peers from the opposite sex.


The parents sought counseling services on recommendation from the school.


Living Situation:

Dalia lives with her parents. She is the youngest of three siblings. Her elder brother moved to another State, while her elder sister is a college sophomore and does not live with the family.

Dependents/Care for Dependents Employment/Disability/Seeking Disability Income/Source of Income:


Insurance Transportation Daily Living Skills:


Social/Leisure Activities:

Dalia has expressed disinterest in any extracurricular activities. She spends her social time with friends, and her parents reported that she took alcohol in their home with her friends.

Available Social Support:

The school does not have a social support group for students. The parents sought the help of a counselor to assist with her behavioral issues.



There are no developmental issues reported


Family of Origin:

Dalia is biracial (African and Irish American), but there are no records beyond this information.

Geographic/Cultural/Spiritual Factors/as Relevant:


Abuse/Trauma History:


Physical/Emotional/Sexual Abuse History: N/A

There are no developmental or historical events that could have initiated the change in behavior in the client. She has no history of sexual, physical, or emotional abuse. However, her disengaged parents precipitated her emotional state.



Cultural/Peer Group/Environment School:

Dalia does not seem to have a good relationship with her peers or the school authorities. She is argumentative and gets combative when confronted about her behavior. Dalia is highly irritable and gets into fights with her peers.


Dalia is highly sexualized toward peers of the opposite sex.


Public or Private School(s) Where Attended:



Dalia was active, participated in activities, loved singing and was good-natured and easy-going prior to middle school. She currently has a very low concentration in school and is disinterested in school activities. She is also a truant and skips school on some days.

Educational Level:

Dalia is in middle school (9th grade – 14 years)

Extracurricular Activities:

Dalia is not involved in any extracurricular activities


What Branch


Duty Assignment (when/where) Rank/Discharge




Family member and relationship:

Dalia has a father, a mother, one brother, and a sister. Their names have not been mentioned.

Relationship dynamics:

Dalia does not have a fulfilling relationship with her mother. She believes her mother is controlling. Her mother is an executive who spends long hours working away from home. Dalia and her mother are hostile to each other. Additionally, Dalia is in the habit of blurting out important information to her mother as her way of sharing what goes on in her life. For example, she had recently ambushed her mother with news of a tattoo she had acquired using a fake ID.

Dalia’s father has a nonchalant relationship with his daughter. Dalia says that he allows her to do whatever pleases her. Her father works through the night and sleeps during the day because of the nature of his job. This means he has limited contact and interaction with his daughter. Dalia’s father believes that she is only going through a teenage phase and does not think his daughter has any major problems.

Dalia perceives her brother to be ‘cool’ and her sister as ‘not cool.’ The relationship with her sister may be tense because of the comparisons that teachers in middle school made of her and her successful and popular sister.


Age of Involvement in Relationships:

14 years

Sexual Orientation:


Length of Relationships:

Not mentioned

Relationship Patterns/Problems:

Risky sexual behavior with different male partners

Partner’s Age/Occupation:

Middle school males



History of Traumatic Injuries/Illnesses/Chronic Health Problems:

Dalia has a history of sickle cell anemia. She was diagnosed in her early childhood. She was often hospitalized because of the illness. Her last serious illness episode occurred two years prior.

Describe Current Illness:

Dalia is exhibiting frequent incidences of irrational behavior. She spends time alone or with friends, during which she consumes alcohol with these friends. Dalia also sleeps during the day and is awake most of the night. She gets into frequent fights and arguments with her peers and is combative toward authority, including her parents. Dalia has also become hypersexual and has also lost all interest in school extracurricular activities. Additionally, Dalia is impulsive and struggles with low self-esteem.

Is Client in Good General Health?

The client is in good physical health but not so with her mental health

Is Client Allergic to Any Medications? Who Is Client’s Primary Care Physician?


Is the Client Being Treated by Any Other Physician(s)?

Dalia has sickle cell anemia as a pre-existing condition. She is currently not receiving treatment for her mental state. It has not been stated whether she has any allergies to specific medications.

What Are the Client’s Current Psychiatric and Non-psychiatric Medications?


Describe Client’s Health Habits: Appetite, Sleep, Exercise, Nicotine, Alcohol, Illicit Drugs, and Vitamins/Herbal Supplements?

Dalia’s sleep patterns have changed. She sleeps during the day and is awake most of the night. She was once active with her peers and family but is no longer interested in getting involved in any activities. Dalia consumes alcohol

Sexual Functioning: Preference/Problems:

Dalia is hypersexual with her male peers.

Pregnancy/Birth Control:

It is not mentioned whether she uses any form of birth control.

Risk Behaviors for STDs:

Dalia is highly sexual, and since it is not mentioned whether she has a single partner, she could be at risk of contracting an STD from her behavior.


Attitude/Appearance/Behavior Affect/Mood/Psychomotor Activity

Orientation/Memory/Cognition Thought Process/Content Speech

Insight/Judgment Homicidal/Suicidal Ideation Hallucination(s)/Delusion(s):

Dalia is an impulsive and angry young adolescent. She is argumentative and openly disagrees with her mother. She also has insecurities as she feels inferior to her sister, a model student. She is not suicidal or delusional. However, she is violent and has been combative with her peers and family members.


Previous Diagnoses/Medications/Inpatient and Outpatient Treatment History of Suicidal Ideation/Suicide Attempts/Self-Mutilation/Homicidal Ideation/Aggression:



Type/Onset/Duration/Amount Frequency/Pattern of Use Involvement in Treatment: Dalia consumes alcohol with her friends. It is not stated when she began to drink alcohol, but it could be around the time her sister left for college. The parents noted that her general behavior changed soon after the sister left.



It is not mentioned whether Dalia or her family members are religious/spiritual or not.


Dalia has lost interest in social activities and engages in drinking alcohol with her friends. Her family reports that she was once easygoing, but that changed and she became more reclusive.


Cultural/ethnic factors:


Personal strengths:

From the parents’ report, Dalia is likable beyond negative behaviors. They also reported that she was social, but the recent changes at home came with a change in her behavior as well. She also seems bold because she got herself a fake ID and a tattoo, two things that need a level of boldness to do.

Family/social resources:

There are no family or social resources mentioned.


The school authority played a significant role in getting Dalia help. They took action and alerted her parents of her changed behavior and even went a step further to recommend a counselor to help her. This shows that the school has a close interest in its students and seeks their well-being.


Dalia is a troubled 14-year-old facing a challenging time with the recent changes in her household. It appears that she found stability when her siblings were living in the house. However, after her brother and especially her sister moved out, Dalia began having coping problems. Her virtually absent parents precipitated the problem. This was in addition to her pre-existing low self-esteem fuelled by her school teachers when comparisons were made between her and her stellar-student sister. The outbursts of anger and aggressive behavior, including alcohol consumption and hypersexuality, indicate an underlying mental problem.


Challenges Faced By The Client

Dalia is the youngest of three children. Her brother and sister have moved out of the house, and she now feels alone. Her parents work hard and for long hours and seem not to have time for her. In addition, Dalia feels lesser than her sister because her Middle school teachers make comparisons of her to her sister, indicating that the latter was a stellar student. Dalia finds comfort in spending time with her friends taking alcohol, and doing impulsive things like faking IDs and getting a tattoo. She is no longer interested in activities like she once used to and prefers to stay up most of the night and sleep during the day. Dalia is also reported as being confrontational, argumentative, and violent toward her peers, authority and family members. In addition, Dalia is hypersexual. She also skips school, and when she does attend, she has poor concentration. Her low concentration, disinterest, abnormal sleep patterns, extreme sexual behavior, irritability, impulsive actions, and truancy are a source of concern and indicators of major underlying issues.

How The Social Environment Affects The Client

Humans have a strong desire for security and safety and intuitively seek these two in the environment they live (Cortini && Liotti, 2010). Humans also seek physical and psychological comfort in their environments. Research shows that a person’s environment can affect one’s mood, motivation to act, behavior, or discourage/ facilitate interactions with others (Sommerville, Jones, & Casey, 2010; Fredrickson & Losada, 2005; McEwen, 2012; Pile, 2010). Dalia spent her early years in a home where all family members were present. However, she now finds herself spending time alone. Her parents work longer than usual, and her father’s working schedule does not allow him to be home in the evenings when Dalia returns from school. Her mother always seems to be busy at work, and that makes Dalia give her information on what goes on in her life in a sporadic way. Dalia spends time alone and feels that her behavior is under more scrutiny. There also seems to be hostility in the home because of her parent’s relationship. Her parents openly argued in front of Dalia, blaming each other for the recent change in behavior. It is likely the parents often argued in front of Dalia when at home as well. Lastly, Dalia’s friends influence her as they support her drinking habit. Because Dalia is often left home alone, her friends can go to her house and consume alcohol.

Human Behavior Theories

Guntrip (2018) states that the psychodynamic theory includes all psychology theories that perceive a human as functioning in the basis of interactions between forces and drives of a person and, more so, unconscious and between the diverse personality structures. The theory assumes that unconscious motives significantly affect a person’s feelings and behaviors. The unconscious mind is the mental process that the conscious cannot access but influence behavior, feelings, and judgments. The decisions, motives, and feelings of a person are powerfully influenced by experiences that occurred in the past but are in the unconscious (Guntrip, 2018).

The psychosocial theory by Erikson (1980) posits that a person’s ego positively contributes to development by mastering skills, ideas, and attitudes through eight stages. During each stage, a person must first overcome a psychological conflict to move to the next level. The eight stages that run from infancy to adulthood are trust versus mistrust; autonomy versus doubt; initiative versus guilt; industry versus inferiority; identity versus role confusion; intimacy versus isolation; generativity versus stagnation; and integrity versus despair. Stokol (2009) notes that when a person fails to master any of the stages, it leads to feelings of inadequacy.

Explain how you would use this assessment to develop mutually agreed-upon goals to be met in order to address the presenting issue and challenges faced by the client.

Dalia’s behavior changes are an unconscious outcome of inbuilt resentment. Additionally, she is in the identity versus role confusion stage in Erikson’s developmental stage. Dalia is trying out different selves to see which one she can fit into (Erikson, 1980). As a social worker, it is paramount that her anger and resentment is addressed. It is also important to help Dalia understand her to need to find an identity and enable her to find it. When adolescents can successfully create an identity they are comfortable with, they can have a strong sense of who they are and remain steadfast to their values and beliefs in times of challenges. Thus, the goals that will be created will focus on developing a strong sense of identity and dealing with the unconscious thoughts that cause her erratic and impulsive behavior.

Explain how you would use the identified strengths of the client(s) in a treatment plan.

Dalia’s parents stated that before her behavior change, she was an outgoing and likeable person who would involve herself in various activities. Dalia is naturally a social person, as witnessed by the fact that despite her irritable mood, she still has friends to socialize with. Her disinterest in participating in activities could be due to her feelings of inferiority. She would probably like to participate in some extracurricular activities but feels that she would not match up to her sister’s performance and hence, chooses to avoid them altogether. This strength can be used in her treatment plan, encouraging her to participate in activities that would impact others positively and in which she can excel. Because Dalia is innately sociable, getting her involved in activities that allow her to meet and interact with people while positively adding value to their lives will help her to become less withdrawn.

Explain how you would use evidence-based practice when working with this client and recommend specific intervention strategies (skills, knowledge, etc.) to address the presenting issue.

The transtheoretical model by Proschaka & Di Clemente (1982) is a behavior change model which can be applied in assisting Dalia in behavior change. The model reflects all the stages an individual makes when going through the different stages of change. It appreciates that behaviour change is a process, not a one-time event. Behavior change involves making decisions and taking action over a period.

Transtheoretical Model

Transtheoretical Model

Fig 1: Transtheoretical Model. Source: Prochaska & Di Clemente, (1982).

When Dalia and her mother gave the intake information, Dalia was in the pre-contemplation stage; she stated that she was ‘ not planning to talk about anything because this meeting was her parents’. The treatment plan will seek to move her thoughts to the contemplation stage where she may desire to change her behaviour after she is made aware of the negative impact of her behavior. The next step will be the preparation to make a change. This will involve listing all the negative behavior and asking her what she dislikes about the behavior. For example, rather than arguing with her parents, would she prefer to have time set apart where she and her parents can have time to talk about all that is going on in her life. The preparation stage will be followed by taking action. This will require her parent’s involvement as well. Dalia needs to spend more time with her parents rather than being withdrawn. She will also need to cut off friends who negatively influence her lifestyle. Additionally, she will need to participate in activities that make her feel useful and positively impact other people’s lives. The final and continuing step is the maintenance of the actions taken in the previous stages. In case of a relapse in behavior, Dalia should have a support system that will help her back on track. Her main support should come from her parents. As mentioned earlier, when people feel secure in an environment, they tend to have a more positive outlook on life and their behavior.

Analyze the ethical issues present in the case. Explain how will you address them.

Truancy is unethical, and this can be addressed by having Dalia first state her reasons for truancy. Her parents can get her additional tutoring classes regarding subjects she finds difficulty coping with. Dalia should be encouraged to write a time plan and adhere to it. Lastly, Dalia should be motivated and given the cons of dropping out of school as well as the benefits of getting a good education.

Disrespecting the school authorities and getting into altercations with her peers is unethical, and the latter can lead to a criminal offense. Dalia should be made aware of the consequences of having a criminal record at a young age. Anger management classes can help her in gaining skills in conflict resolution. Breathing lessons can be administered to help Dalia calm down whenever she finds herself in a potentially violent situation.

Describe the issues will you need to address around cultural competence.

Dalia needs to learn how to interact with people from different cultures. Her altercations and arguments with authorities indicate that she does not respect culture or is unaware of the cultural expectations of young people toward society. To address the deficiency, Dalia will need to take communication skills classes to learn how to communicate effectively and be an active and patient listener, all of which will help her be a better communicator. Effective communication will allow for more understanding and fewer or no misunderstandings and combativeness.


Cortina, M., & Liotti, G. (2010). Attachment is about safety and protection, intersubjectivity is about sharing and social understanding: The relationships between attachment and intersubjectivity. Psychoanalytic Psychology27(4), 410.

Erikson, E. H. (1980). Elements of a psychoanalytic theory of psychosocial development. The course of life: Psychoanalytic contributions toward understanding personality development1, 11-61.

Fredrickson, B. L., & Losada, M. F. (2005). Positive affect and the complex dynamics of human flourishing. American psychologist60(7), 678.

Guntrip, H. Y. (2018). Personality structure and human interaction: The developing synthesis of psychodynamic theory. Routledge.

McEwen, B. S. (2012). Brain on stress: how the social environment gets under the skin. Proceedings of the National Academy of Sciences109(Supplement 2), 17180-17185.

Pile, S. (2010). Emotions and affect in recent human geography. Transactions of the Institute of British Geographers35(1), 5-20.

Prochaska, J. O. & Di Clemente, C. C., (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19(3), 276-288. Figure 2, p. 283.

Somerville, L. H., Jones, R. M., & Casey, B. J. (2010). A time of change: behavioral and neural correlates of adolescent sensitivity to appetitive and aversive environmental cues. Brain and Cognition72(1), 124-133.


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Bio-Psycho-Social Assessment

SOCW 6200 Final Project: Bio-Psycho-Social Assessment Submit by Day 7 a 6- to 9-page paper that focuses on an adolescent from one of the case studies presented in this course. For this assignment, complete a bio-psycho-social assessment and provide an analysis of the assessment. This assignment is divided into two parts (Part A & Part B):

Part A: Bio-Psycho-Social Assessment: The assessment should be written in professional language and include sections on each of the following:

Bio-Psycho-Social Assessment

Bio-Psycho-Social Assessment

  1. Presenting issue (including referral source)
  2. Demographic information
  3. Current living situation
  4. Birth and developmental history
  5. School and social relationships
  6. Family members and relationships
  7. Health and medical issues (including psychological and psychiatric functioning, substance abuse)
  8. Spiritual development
  9. Social, community, and recreational activities
  10. Client strengths, capacities, and resources

Part B: Analysis of Assessment. Address each of the following:

  • Explain the challenges faced by the client(s)—for example, drug addiction, lack of basic needs, victim of abuse, new school environment, etc.
  • Analyze how the social environment affects the client.
  • Identify which human behavior or social theories may guide your practice with this individual and explain how these theories inform your assessment.
  • Explain how you would use this assessment to develop mutually agreed-upon goals to be met in order to address the presenting issue and challenges face by the client.
  • Explain how you would use the identified strengths of the client(s) in a treatment plan.
  • Explain how you would use evidence-based practice when working with this client and recommend specific intervention strategies (skills, knowledge, etc.) to address the presenting issue.
  • Analyze the ethical issues present in the case. Explain how will you address them.
  • Describe the issues will you need to address around cultural competence.

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