Biopsychosocial AssessmentThe purpose of this assignment is to implement the assessment
skills, concepts, theories and various interventions that you have learned in class (and from
other courses) using a biopsychosocial framework. Utilizing this framework student’s will be
expected to develop an extensive, in-depth analysis of a case that you been working with this
year (see template for structure and categories for assessment). For example, such skills and
theories may include the ecological perspective, strengths perspective, client joining skills, crisis
intervention, mental status exam and concepts associated with advanced generalist practice. In
addition, students will be expected to create an ecomap or genogram of the client system.
Finally, students will provide a formulation of their case and discuss a treatment/intervention
plan including treatment goals and critical reflections on how the beginning therapeutic
relationship seems to be progressing
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Biopsychosocial Assessment
Instructions: This assignment is broken down into two sections: a) the biopsychosocial
assessment and, b) assessment review and critique. Review and respond to each section of the
assignment. Use headings and subheadings to organize your work. You will write Part A of the
assignment as if you were completing a biopsychosocial on a client system.
Part A: 10-12 pages
Descriptive and analytic biopsychosocial assessment
Using the integrated approach in the Cooper & Lesser Chp. The Psychosocial Study, briefly
describe:
identifying information,
presenting problem,
history of the problem
family background
personal history
medical history
educational/learning history
strengths/competencies
socio-economic status
cultural history – including issues of race, ethnicity, gender, sexual orientation, age, and
disability as they affect current functioning for this client
religion/spirituality
mental status exam
Attach an ecomap depicting the social and transactional contexts within which the client is
embedded. Think systemically.
Assessment Summary
Discuss here your overall formulation of the case (what you think is going on).
Provide information that supports how you arrived at this formulation.
Think systemically. NO NEED FOR DSM 5 Diagnosis. You can simply identify client symptoms.
Goals/objectives for Treatment/Intervention
Develop a set of measureable goals/objectives. Use any of the models discussed in class or
those you read in course reading materials. (i.e. SMART goals, task-centered).
II. Part B 4-6 pages
Assessment Review and Critique: In this section, you should use citations/references to support
your work. (if you used a hypothetical case, project what you might have experienced in order
to answer these questions):
Application of Course Content
Discuss whether the identified goals were established mutually or externally imposed.
What specific brief change orientated strategies and/or interventions might be employed with
this client to help them reach their goals? For example, cognitive restructuring, crisis
intervention, solution focused.
Specifically describe how you plan to evaluation the client’s status in terms of progress.
(evaluation plan)
Clearly discuss how you utilized the various integrated conceptual/theoretical frameworks for
assessment purposes. Relate at least two frameworks/perspectives of the following to your
client system- generalist perspective, strengths perspective, ecological perspective, systems
theory. Keep in mind any human behavior theories that may be relevant as well. This may
require you to identify the various concepts associated with these frameworks.
Reflection and Critique
What personal values were challenged in working with the client (think in terms of diversity and
difference)? How did you manage any value differences? What possible similar values were
present and how did you use those in developing your working relationship with the client?
What were the biggest challenges you faced in developing and sustaining the relationship with
the client?
Discuss any transference and counter-transference concerns that resulted as part of this
assessment.
What did you do well? What areas were missed? Upon reflection and introspection what would
you do differently with this case? What are the ongoing areas of practice that you need to
continue to refine and develop?
CASE 1 M. is a 16 year old African American female in the 10 grade. She is from a two
parent working class family. Her urban neighborhood is well established and generally
considered safe. M. is at an highly regarded alternative high school that addresses the
needs of adolescents with learning disorders and emotional/behavioral problems. M.
was referred by her mother to this outpatient clinic for support with friends and school.”
During the assessment M. reveals she has had one parasuicide attempt 3 months ago
where she swallowed a bottle of pain medication from her parents’ medicine cabinet.
This was in the context of her best friend becoming distant toward her and ceasing
communication. M. was both shocked and hurt when her BFF suddenly “defriended her”
despite their intense and longstanding connection. She immediately told her mother and
was driven to the hospital where she had her stomach pumped. M. was hospitalized for
a few days and then released without a follow up plan except individual therapy. Now 3
months since that event, M. has remained stable and reunited with her best friend. Her
parents are committed to M’s wellbeing and are anxious that she remain in therapy.
Upon intake she states she has been in therapy elsewhere, but the therapist felt it was
time for her to seek another therapist and “gain a different perspective.”
M’s learning disorder was identified in the 3rd grade and she has received educational
services since that time. From the 6th grade through 8th grade M. and a close friend
experimented with superficial cutting on wrists using sharp objects. M. claims that she
no longer cuts having “grown out of this behavior.” M. was able to succeed in a
mainstream school setting until the 10th grade. As the academic demands of school
increased M. began to fall behind and she started smoking pot on a daily basis. She
frequently got into fights with her peers and was unmotivated in class and isolative at
home. At that time M. was transferred to a “satellite” alternative school connected to her
high school. Initially M. was angry and despondent about the transfer and didn’t want to
leave her peers. With time she has made new friends and her academics are wishes to
graduate from this high school and no longer misses her old one. M. has reduced her
pot use but still smokes weekly and maintains this is the “best she can do.”
M. is superficially pleasant and appears relaxed in the sessions. She stretches out on
the couch and when asked how things are going she states that “everything is great.”
By her account things are “fine at home;” she has good friends and she is successful at
school. Her parents confirm this account.. M. answers all the questions from her
therapist and seems unconcerned about events of the past chalking them up to “a
stupid mistake ’cause everything seemed dark and hopeless in the moment…but it’s all
good now.” Although plausible, the therapist feels there is something missing in M’s
account. She denies a history of SI and maintains this was a “one-time event.”
When M. missed an appointment her therapist called home and learned that she had
been found hanging by a rope in an attached shed, suspended from a rafter. She was
unconscious and blue and close to death. Prior to this attempt M. had shared breakfast
with her parents, chatting happily and making plans for the weekend. Her parents report
she gave no indications that anything was wrong. They follow up in person with the
therapist and are in shock.