Long Island University Brooklyn Chapter 1 Biopsychosocial Assessment Analysis Essay

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Biopsychosocial Assessment Format

  1. Identifying Information
    1. Clientname
    2. Demographicinformation:age,gender,genderidentity;race/ethnicity;sexualorientation;current employment, marital status; language spoken; socioeconomic status: What entitlements does the client receive (SNAP benefits; food assistance, rental assistance, child support services, career services; assistance with utilities; disability services?)
    3. Briefmentalstatusexam(i.e.,appearance,attitude,behavior,speech,affect,mood).
    4. Referralinformation:referralsource(selforother),reasonforreferral.Otherprofessionalscurrently involved.
  2. Presenting Problem
    1. Descriptionoftheproblem:Client’sdefinitionoftheproblem/need.Usetheclient’swords.
    2. Historyofthepresentingproblem:Lengthordurationoftheproblem(i.e.,howlonghastheproblem been going on?) What precipitating stressors or events brought on the current problem? What feelings and thoughts have been aroused? How has the client coped so far? Prior attempts to resolve the problem. Who else is involved in the problem? How are they involved? How do they view the problem? How have they reacted? How have they contributed to the problem or solution? Past experiences related to current difficulty. Has something like this ever happened before? If so, how was it handled then? What were the consequences? Previous involvement with social agencies for assistance with the problem. If client is in crisis or considered "high risk" (i.e., in danger of harm to self or others, you should describe and offer a brief assessment of the risk).

SWK 650 – Summer 2021 (Rivera)

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  1. Background History
    1. Developmentalhistory:fromearlylifetopresent
    2. Familybackground:descriptionoffamilyoforiginandcurrentfamily.Extentofsupport.Familyperspective on client and client’s perspective on family. Family communication patterns. Family’sinfluence on client and intergenerational factors.
    3. Socialfunctioning:Arethereanysignificantfriendships,interpersonalrelationships,supportnetwork? Use of community organizations or resources (e.g., as client, member, volunteer)?Hobbies/leisure involvement
    4. Educationaland/orvocationaltraining:Highestlevelofeducation;Degree/searned;Specialschool/educational talents, challenges, goals
    5. Employmenthistory:Occupation,workhistory,andcurrentstatus(e.g.,employed,unemployed,full-time, part-time; disability). Special training/skills. History of work habits (timeliness, insubordination, ability to fulfill work duties). Reason(s) for leaving (e.g., terminated; history of terminations; relocated)
    6. Military history (if applicable): Is client a U.S. Veteran?
    7. Use and abuse of alcohol or drugs, self and family
    8. Medicalhistory:birthinformation,illnesses,accidents,surgery,allergies,disabilities,healthproblems in family, nutrition, exercise, sleep
    9. Mental health history: previous mental health problems and treatment, hospitalizations, outcomeof treatment, family mental health issues.
    10. Significant events: deaths of significant others, serious losses or traumas, significant lifeachievements
    11. Legalconcerns(ifapplicable):Immigrantstatus,housing,maritalissues,domesticviolence,parole/probation, DWI's?
    12. Cultural background: race/ethnicity, primary language/other languages spoken, significance ofcultural identity, cultural strengths, experiences of discrimination or oppression, migrationexperience and impact of migration on individual and family life cycle.
    13. Religion: denomination, church membership, extent of involvement, spiritual perspective, specialobservances
  2. Assessment
    1. Whatisthekeyissueorproblemfromtheclient’sperspective?Fromtheworker’sperspective?
    2. Howeffectivelyistheclientfunctioning?
    3. Whatfactors,includingthoughts,behaviors,personalityissues,environmentalcircumstances,psychosocial stressors (e.g., bereavement, domestic violence), vulnerabilities, and needs seem to be contributing to the problem(s)? Please use systems theory with the ecological perspective as a framework when identifying these factors.
    4. Identifythestrengthscopingability,andresourcesthatcanbemobilizedtohelptheclient.
    5. Assess client’s motivation and potential to benefit from intervention
  3. Recommendations/Proposed Intervention
    1. Problem
    2. Tentative Goals (with measurable objectives and tasks)
      1. One Short-term
      2. One Long-term
    3. Possibleobstaclesandtentativeapproachtoobstacles

SWK 650 – Summer 2021 (Rivera)

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DSM-5 DIAGNOSIS

In this section, provide a diagnosis for the client. In narrative form, defend your diagnoses. Use DSM-5 criteria and your knowledge of the etiology of the conditions to support your choices.

You will need to give very specific details and use the DSM-5 approach to formulating the diagnosis. The paper must include a paragraph of each of the following:

  • Type of disorder
    • Symptoms
    • Illustrate the key aspects of making a differential diagnosis. • What diagnoses would you rule out and why?
  • CASE FORMULATION (Clinical Summary, Impressions, and Assessment)

    The case formulation is an attempt to bring together a number of important factors and create a summary of the case and its many facets. This is the most important part of the biopsychosocial assessment, as it demonstrates your ability to synthesize all of the information you have collected during the assessment process. It also demonstrates your clinical assessment of the client’s condition, while taking into consideration all of the biological, psychological, and social factors influencing the client’s overall functioning. These factors ought to include history, functional status, and resource information about the client. The mental status and diagnosis should be consistent with the client’s presenting problem and personal history.

    This section must also demonstrate your knowledge and application of theory. Specifically, you should demonstrate your knowledge of the strengths-perspective and the ecological perspective (Gray & Zide, Chapter 1) in your understanding of the client. You should cite the course text and 3 peer reviewed journal articles on the topic. For example, if the “client” is diagnosed with Bipolar Disorder, your articles should address practice issues related to Bipolar disorder (e.g., suicide risk in bipolar disorder). Your paper must be written in APA style format.

    The clinical summary, impressions, and assessment section should:
    • First give a brief, 3-5 sentence summary of what you have already written:

    o Theclient’schronologicalageandthedevelopmentalstageandtaskthatisappropriateforthat particular age.

    o Identifytheprimaryproblem,need,orconcerntheclientisdealingwithandcontributingfactors. o Also,describethesenseofurgencytheclienthaswiththeproblem/s.
    o Identifysecondaryproblems,needs,orconcernsiftheseareraised.
    o Whatresourcesareavailabletotheclientandtheclient’ssupportsystem?

  • Summarize how the client appeared during the interview/s.
    o Giveanoverviewofclient'smood,signsofanxietyordepression,problemswithmemory,
  • speech, sense of reality, judgment, attitude toward their situation/difficulty.
    o Indicatehowtheclientrelatedtoyou.Yourimpressionsgiveimportantcluestowheretheclient

    is right now and how the client is handling the problem emotionally and cognitively.

    • Goals and Recommendations for work with the cliento Identifygoalsforworkwithclient.
      o Recommendationsforserviceandresources§ Modality (what type of treatment?)
      § Length of time (how many sessions? Long term, short term?) § Next steps
    • Note the client's expectations of service.
    • Note your assessment of the client's motivation for change and likely use of service.

    Unformatted Attachment Preview

    SWK 650 – Summer 2021 (Rivera) Final Paper Biopsychosocial Assessment This assignment is designed to give you an opportunity to apply theoretical knowledge that you have gained in the course to your diagnostic work with clients. This assignment is worth 35% of your final grade. A grading rubric for this assignment is included below. Assignment Due Date: Thursday, August 12, 2021 by 11:59PM For this assignment, you will develop a biopsychosocial assessment and intervention plan. You should select a specific psychological disorder that will be the focus of your paper. For the purpose of this assignment, you can select any of the adolescent or adult disorders covered in the DSM-5 (ages 15+). You must develop a specific case study, or detailed description of a person with this problem. Your case study can either be based on a client you are currently working with in your field placement, or you can develop one of your own (e.g., based on a film). You will gather relevant information from the “client” using the biopsychosocial framework (required format below) and formulate a DSM-5 diagnosis based on the client’s information, and on applied theory relevant to the client’s case. You will then write a case formulation according to the specifications below. Instructions: Use the headings and subheadings listed below in your paper. The completed assignment will be a maximum of 8 pages typed, double-spaced, with one-inch margins and 12-point font size, Times New Roman. You must also include a title page for this assignment and separate list of references. This assignment must be submitted via Blackboard in: Assignments tab on Blackboard. Biopsychosocial Assessment Format I. Identifying Information A. Client name B. Demographic information: age, gender, gender identity; race/ethnicity; sexual orientation; current employment, marital status; language spoken; socioeconomic status: What entitlements does the client receive (SNAP benefits; food assistance, rental assistance, child support services, career services; assistance with utilities; disability services?) C. Brief mental status exam (i.e., appearance, attitude, behavior, speech, affect, mood). D. Referral information: referral source (self or other), reason for referral. Other professionals currently involved. II. Presenting Problem A. Description of the problem: Client’s definition of the problem/need. Use the client’s words. B. History of the presenting problem: Length or duration of the problem (i.e., how long has the problem been going on?) What precipitating stressors or events brought on the current problem? What feelings and thoughts have been aroused? How has the client coped so far? Prior attempts to resolve the problem. Who else is involved in the problem? How are they involved? How do they view the problem? How have they reacted? How have they contributed to the problem or solution? Past experiences related to current difficulty. Has something like this ever happened before? If so, how was it handled then? What were the consequences? Previous involvement with social agencies for assistance with the problem. If client is in crisis or considered "high risk" (i.e., in danger of harm to self or others, you should describe and offer a brief assessment of the risk). 1 SWK 650 – Summer 2021 (Rivera) III. Background History A. Developmental history: from early life to present B. Family background: description of family of origin and current family. Extent of support. Family perspective on client and client’s perspective on family. Family communication patterns. Family’s influence on client and intergenerational factors. C. Social functioning: Are there any significant friendships, interpersonal relationships, support network? Use of community organizations or resources (e.g., as client, member, volunteer)? Hobbies/leisure involvement D. Educational and/or vocational training: Highest level of education; Degree/s earned; Special school/educational talents, challenges, goals E. Employment history: Occupation, work history, and current status (e.g., employed, unemployed, full-time, part-time; disability). Special training/skills. History of work habits (timeliness, insubordination, ability to fulfill work duties). Reason(s) for leaving (e.g., terminated; history of terminations; relocated) F. Military history (if applicable): Is client a U.S. Veteran? G. Use and abuse of alcohol or drugs, self and family H. Medical history: birth information, illnesses, accidents, surgery, allergies, disabilities, health problems in family, nutrition, exercise, sleep I. Mental health history: previous mental health problems and treatment, hospitalizations, outcome of treatment, family mental health issues. J. Significant events: deaths of significant others, serious losses or traumas, significant life achievements K. Legal concerns (if applicable): Immigrant status, housing, marital issues, domestic violence, parole/probation, DWI's? L. Cultural background: race/ethnicity, primary language/other languages spoken, significance of cultural identity, cultural strengths, experiences of discrimination or oppression, migration experience and impact of migration on individual and family life cycle. M. Religion: denomination, church membership, extent of involvement, spiritual perspective, special observances IV. Assessment A. What is the key issue or problem from the client’s perspective? From the worker’s perspective? B. How effectively is the client functioning? C. What factors, including thoughts, behaviors, personality issues, environmental circumstances, psychosocial stressors (e.g., bereavement, domestic violence), vulnerabilities, and needs seem to be contributing to the problem(s)? Please use systems theory with the ecological perspective as a framework when identifying these factors. D. Identify the strengths coping ability, and resources that can be mobilized to help the client. E. Assess client’s motivation and potential to benefit from intervention V. Recommendations/Proposed Intervention A. Problem B. Tentative Goals (with measurable objectives and tasks) 1. One Short-term 2. One Long-term C. Possible obstacles and tentative approach to obstacles 2 SWK 650 – Summer 2021 (Rivera) DSM-5 DIAGNOSIS In this section, provide a diagnosis for the client. In narrative form, defend your diagnoses. Use DSM-5 criteria and your knowledge of the etiology of the conditions to support your choices. You will need to give very specific details and use the DSM-5 approach to formulating the diagnosis. The paper must include a paragraph of each of the following: • Type of disorder • Symptoms • Illustrate the key aspects of making a differential diagnosis. • What diagnoses would you rule out and why? CASE FORMULATION (Clinical Summary, Impressions, and Assessment) The case formulation is an attempt to bring together a number of important factors and create a summary of the case and its many facets. This is the most important part of the biopsychosocial assessment, as it demonstrates your ability to synthesize all of the information you have collected during the assessment process. It also demonstrates your clinical assessment of the client’s condition, while taking into consideration all of the biological, psychological, and social factors influencing the client’s overall functioning. These factors ought to include history, functional status, and resource information about the client. The mental status and diagnosis should be consistent with the client’s presenting problem and personal history. This section must also demonstrate your knowledge and application of theory. Specifically, you should demonstrate your knowledge of the strengths-perspective and the ecological perspective (Gray & Zide, Chapter 1) in your understanding of the client. You should cite the course text and 3 peer reviewed journal articles on the topic. For example, if the “client” is diagnosed with Bipolar Disorder, your articles should address practice issues related to Bipolar disorder (e.g., suicide risk in bipolar disorder). Your paper must be written in APA style format. The clinical summary, impressions, and assessment section should: • First give a brief, 3-5 sentence summary of what you have already written: o The client’s chronological age and the developmental stage and task that is appropriate for that particular age. o Identify the primary problem, need, or concern the client is dealing with and contributing factors. o Also, describe the sense of urgency the client has with the problem/s. o Identify secondary problems, needs, or concerns if these are raised. o What resources are available to the client and the client’s support system? • Summarize how the client appeared during the interview/s. o Give an overview of client's mood, signs of anxiety or depression, problems with memory, speech, sense of reality, judgment, attitude toward their situation/difficulty. o Indicate how the client related to you. Your impressions give important clues to where the client is right now and how the client is handling the problem emotionally and cognitively. • Goals and Recommendations for work with the client o Identify goals for work with client. o Recommendations for service and resources § Modality (what type of treatment?) § Length of time (how many sessions? Long term, short term?) § Next steps • Note the client's expectations of service. • Note your assessment of the client's motivation for change and likely use of service. 3 SWK 650 – Summer 2021 (Rivera) Grading Rubric for Biopsychosocial Assessment Excellent (5 Points) Problem Focus Problem focus for the paper is clearly defined; meets all criteria for this assignment. Good (4 Points) Fair (2 Points) Problem focus is relatively clearly defined; meets most criteria for this assignment. Problem focus is not clearly defined; topic is not appropriate for this assignment. Presenting problem Presenting problem is Presenting problem is clearly and succinctly relatively clearly stated. stated. Presenting problem was poorly stated. Brief Mental Status Exam Mental status exam is complete and consistent with presenting problem. Mental status exam generally descriptive and somewhat consistent with presenting problem. Mental status exam is unclear, inaccurate, and/or inconsistent with presenting problem. Background History Comprehensive background history, including detailed personal and family background. Background history is satisfactory. Background history is marginal/incomplete. Diagnosis Diagnosis done correctly, and consistent with presenting problem and personal history. Primary diagnosis is accurate. Diagnosis is inaccurate. Case Formulation Case formulation took all relevant factors into consideration and used appropriate theoretical framework as a foundation for assessment. Case formulation reflects Case formulation is not a moderate based upon any theoretical understanding and uses framework. a theoretical formulation to explain presenting issues. Overall Well written and professionalism organized professional of document document that covers all relevant areas. Total Points Achievable Well written and organized professional document that covers most relevant areas. Poorly written and organized; does not follow required format. 35 4
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    Explanation & Answer

    View attached explanation and answer. Let me know if you have any questions.

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    Biopsychosocial Assessment
    Name
    Professor
    Course
    Date

    2

    Biopsychosocial Assessment
    Identification Information
    Client name; David Green, 46 years old masculine male. He is non-Hispanic white
    communicating fluently in English. Mr. Green was initially married with a heterosexual
    orientation but is currently divorced. However, the middle-income man working as a teacher
    in the neighboring school and runs a small-scale grocery shop.
    Mr. Green visited the clinic appearing dull with unkempt hair, clothes with missing
    buttons, and walked slowly, taking smaller steps. In the examination room, the client seemed
    to be motionless and quiet. He displayed a flat affect, as he talked with the dull and low tone
    with incoherent words at some point. He seemed to be depressed, irritable, angry, and
    resentful.
    The client was referred by his general practitioner with complaints of insomnia, lack
    of appetite, headache, weight loss, and generalized body weakness. His general practitioner
    referred him following a thorough history which elicited psychological disturbance.
    However, physical examination and diagnostic tests were undiagnostic but symptoms
    persisted despite initial treatment.
    Presenting Problem
    The patient reported having sleepless nights despite taking the advice he received
    prior in an attempt to solve the problem. He says ‘I have been having trouble with finding
    sleep’. He adds, ‘I have lost weight, I am unable to eat as I always feel full and not interested
    in food or drinks. I have been unable to interact with my colleagues and friends at work, most
    of the time I find myself alone and talking to myself. He continues to say ‘I cannot have fun
    as nothing makes sense or makes me happy anymore, I am finding myself having conflicts
    with other people due to bursts of anger.’

    3

    The symptoms have been present for five weeks since he noticed changes in his
    lifestyle. Mr. Green, however, says the problem started when his wife took everything they
    had and filed a divorce case. Since then, he says things have not been the same, he says he
    feels betrayed, unwanted, admiring death, and worthless. After having such an experience,
    the client sought help from his parents, the elder brother, and his clergy. He narrates he was
    counseled but that has not worked for him as he feels troubled more than before. His family,
    however, has encouraged him to seek help from the health care providers and seek legal help
    to reclaim his property.
    The client reports that he previously had a problem with his wife before, which
    involved violence but the problem was resolved by local authorities. However, the client is in
    crisis and at high risk for self-harm or suicidal attempt. The decision was made after
    conducting an assessment on the client. The criterion that was used to assess the client. Sex
    where males are at high of suicide and harm. Additionally, living alone has a feeling of lack
    of self-worth, presence of suicidal thoughts, and anhedonia. Other symptoms of self-harm
    and others include irritability, anger and resentments also indicated that the client was at high
    risk for self-harm or others (Choo et al., 2019).

    4

    Background History
    Developmental history
    Mr. Green was born 46 years ago, however, since birth, his growth and development
    have been consistent with that of acceptable milestones. During the conception period, the
    mother got the right care and birth took place in a hospital with no compl...


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