BIO-PSYCHOSOCIAL PART A

Bio-Psychosocial History
February 15, 2013
Esther Mason
ID # 004295333
SW 3020

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Introduction

I will be discussing the bio-psychosocial history conducted of an older acquaintance of

mine. As instructed, I will be identifying them using a pseudonym. I will be attempting to
develop a complete file for the assessment and development of a person-centered plan. The biopsychosocial will include an eighteen-part assessment detailing such information as family of
origin history, religious history, health and developmental history. This process will familiarize
me a method of client assessment that takes into consideration the different systems, which
directly affect the current issues and strengths of the individual. It will also allow me to develop
a complete case file, which includes my clients past history and current situation. It will provide
me with information about my clients personal experiences with problems and past problem
solving behaviors. In addition to building a sound foundation for generalists practice knowledge
it will enhance the oral and written language skills that are required for professional
communications.
Analysis
My clients name is Jane Smith (a pseudonym). Jane currently lives in an eastern suburb
of Detroit with her daughter. She currently resides in the home that she and her now deceased
husband raised their family in. Jane seems to take great deal of pride when discussing how hard
she and her husband worked to make ends meet during the leaner years. Her sense of
accomplishment was obvious due to the upbeat tone in her voice. When I asked her if she was
experiencing any problems other than her medical issues she paused and when she resumed
talking, the tone in her voice was lower and her word became deliberate as if she were squeezing
them out. Jane states that she has been noticeably tired for the past several months and just does
not seem to have the energy to do much of anything. She has mentioned a loss in appetite and a

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disinterest in the small hobbies she once enjoyed. As Jane begins describing her current state I
notice a slight change in her demeanor, her gaze begins to cast slightly downward and I notice
her shoulders rising slightly. As she continues to describe her current emotional state she begins
to gently ring the tissue in her hands. Jane states that she feels as if she is a burden on her
daughter. She goes on and states that some days are better than others but on her bad days she
can hardly muster up the energy to drag herself out of bed, let alone tend to her most basic needs.
Then with a slight smile, Jane says that on days like that her daughter simply pesters her until she
snaps out of it. It appears that there is a great deal of love and devotion between Jane and her
daughter. Jane states that her greatest complaint is that her body cannot keep up with her mind.
The one thing I did notice about Jane is how vivid and accurate her memory was, she had very
little difficulty recalling instances and dates from her past.
Family of Origin
Jane was born on May 10, 1938 in a Catholic poor house and by the time she was six
weeks old she was adopted by what she considers her only parents. Little is known about the
circumstances surrounding Janes birth and she states that is the way she wants to keep it. When I
asked her how old was she when she found out she was adopted she stated that she always knew.
Jane identifies as Caucasian but also states her parents were Italian immigrants. Janes mother,
Cora was born August 20, 1913. She passed away in the winter of 1993 at the age of 80 from the
effects of cardiac failure. Janes father, Percy was born June 19, 1903 and passed away in the fall
of 1967 at the age of 54 from a stroke. She stated that because her parents were Italian she had a
great number of relatives, but because her parents were unable to have children of their own she
was an only child. She went on to state that even though she was an only child her parents

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always allowed two of her favorite cousins to stay with them during the summers. Jane stated
that because she was a member of a loud extended Italian family she very seldom got lonely
Developmental and Current Health History
Jane states that by the age of ten months she was walking unassisted. Jane was unable to
recall if she had been told at what age she was potty trained. Her childhood illness consisted of a
case of the chicken pox at age 5 and the occasional cold. She stated as far as she can remember
she was relatively healthy. When asked about any current health issues Jane said she was
diagnosed with rheumatoid arthritis in her lower extremities approximately ten years ago. Since
then she has become progressively immobile and now requires a wheel chair when venturing
outside the house and relies heavily on her walker inside the home. This past October Janes
physician determined she was diabetic and she was placed on oral medication and a strict diet.
When asked about any history of substance abuse or mental health issues she simply answers no
Relationship History
When asked about childhood relationships she stated she had on special friend who she
adored, but she developed leukemia and passed away before her eleventh birthday. She stated
after her friends death she spent most of her free time with cousins her age. When asked to
elaborate on her feelings for her friend she simply stated I really loved her. Her dating history
was also short also. Jane stated she only dated one other boy when she was fifteen. She explained
he was a coworker at the only job she ever had, but because her parents did not approve the
relationship ended. When asked about her sexual history she simply stated she wasnt that kind
of girl. Jane did elaborate some on her sexual history but I included that in her family of creation
history. As I stated before Jane currently resides with her daughter in their family home. She
currently has no mate and when asked the question she stated that one husband was more than

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enough for her. Janes states her relationship with her son is strained and due to his substance
abuse and that she only sees him occasionally.
Family of Creation History
Jane is a widow and her husband Michael died of a massive heart attack at the age of 52,
by what appears to be lifestyle circumstances. Jane stated that he was a heavy drinker, and
according to her he smoked cigarettes like a chimney... Jane has two children, a daughter named
Mary who is 57 years old and a son named Thomas who she loving refers to, as her change of
life baby is 30 years old.
Jane attended Detroit public schools until she was 15 years old. At the age of 15 Jane
began working in a large hotel as a maid. She said she loved the independence she felt when
earning her own paycheck. Jane stated that her parents were very protective of her and wanted
her to stop working and find a husband to settle down with. This concept was not unusual for a
traditional Catholic family during that time period. By the time Jane was sixteen her cousins
arranged a meeting with a nice Catholic man by the name of Michael. Even though Jane was not
in love with Michael, he possessed all the qualities her family wanted in a son in law. So she
married him a year later. Jane stated that on her wedding night she knew little to nothing about
the fundamentals of marital sex. She claims that the only pleasure she received from the act was
when it was done. Two years later Jane gave birth to a 7-pound healthy baby girl. Jane gave
birth in what was considered the accepted method at time, under heavy sedation. She recalled it
as if it were yesterday. Jane stated if it had not been for the birth of Mary she would have
eventually hung herself. She stated that the earlier years of her marriage were no more than an
endless cycle of cooking and cleaning and taking care of someone that she had little feelings for.
But eventually she grew to care for Michael and life became less difficult. Jane stated that even

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though Mary was her light at the end of the tunnel she wanted nothing to do with the process of
making another child. When I asked Jane what kind of birth control they had back then she
simply stated that Catholics do not use birth control, but if you didnt want any more children
you figured out a way. Jane stated that as time went on she did her best to raise Mary right; they
placed her in Catholic school and became members of their local parish. Eventually Mary grew
up and got married just after graduating high school, and started her own family. Jane stated that
by the time she was 45 years old she had adjusted to her life and was becoming content. During
this time Jane says that she and Michael began planning for their retirement Then Jane stated that
God had other things in store for her, and what Jane thought was the onset of menopause was
actually her second pregnancy. So she and Michael had their second child in June of 1982, it was
a vaginal delivery and the child was a healthy 5 pounds and 6 ounces. Given their faith there
were no other options. Jane was 45 and Michael was 52 at the time, six months later Michael
dies of a coronary event. Jane stated that she was terrified, not so much by losing her husband;
she stated that death was a part of life. What terrified her the most was the challenge of having to
raise their infant son alone.
Jane stated that unlike Mary, Thomas was always a handful. When asked to elaborate on
the statement she simply said she was too old when he was born. When asked what methods they
used to discipline their children she stated that a belt was the preferred method but most times it
was whatever she could get her hands on.
When asked about her childrens marital history she stated she was uncomfortable
answering any questions about that but she, did mention that Mary was divorced and Thomas has
never been married. In addition she did mention that both children have given her a total of five
grandchildren.

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Religious History

When asked about her familys level of involvement in their religion, she stated that it
was no more or less involved that the average Catholic family. She also stated that there were no
nuns or priests in the family but they attended mass weekly. She also stated that she still attends
mass if she feels well enough.
Employment History
When asked about any other employment history Jane states that she worked
intermittently after her husbands death. These jobs included a short stint as a waitress and
occasional house cleaning positions.
Strengths
As I have mentioned the devotion that both Jane and Mary have for one another is to be
commended. Mary relies on Jane just as much as Jane relies on her. Another one of Janes
strengths lies in her mental alertness and her ability to remember past events with extreme
accuracy. In addition to the previously mention qualities Jane also has a wicked sense of humor.
All throughout the assessment she would crack jokes about aging and life in general. Jane
possesses a healthy outlook on life and death she has faced all her lifes challenges with grace
and fortitude.
Conclusion
Going through the process of taking a complete and thorough assessment appears to be an
ongoing process. I am quite sure Jane would have been more willing to share information if we
had a second of third meeting. Having first handed experience with the assessment process felt
challenging at first but when I ignored my own anxiety it became wonderfully consuming. This

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assignment afforded me the necessary experience to practice my communication skills, and I am

looking forward to completing part B.
Education History
As I stated previously Jane attended public schools until she quit at the age of 15. When
asked about relationships at during this time she mentioned a female class mate and neighbor,
named Elizabeth. She stated they were 10 years old and that she truly loved her. When asked
what she meant by truly loved, she stated I just loved her. She went on to state that when
Elizabeth died she was heartbroken. Accepting the fact that she did not want to discuss Elizabeth
I asked why she didnt complete high school. Her response was, girls were not expected to get an
education they were expected to get a husband and family and in that order. When asked to
elaborate on her statement she said that boys were encouraged to learn whereas girls were
discouraged. I believe Janes leaving school and eventual marriage was only done because of
family and societal expectations at that time.
Health history
Her childhood illness consisted of a case of the chicken pox at age 5 and the occasional
cold. She stated as far as she can remember she was relatively healthy. When asked about any
current health issues Jane said she was diagnosed with rheumatoid arthritis in her lower
extremities approximately ten years ago. Since then she has become progressively immobile and
now requires a wheel chair when venturing outside the house and relies heavily on her walker
inside the home. This past October Janes physician determined she was diabetic and she was
placed on oral medication and a strict diet.

Medications

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She states that she is currently taking two different medications for her arthritis one is
Humira the other is Methotrexate. Jane stated that her doctor prescribed Glucophage for her this
past fall, but recently told her, if she continues her diet she may not need the medication. Clearly
Jane still cares about her health due to the fact that she has maintained a healthy diet

Psychiatric History
Jan stated that she has never received any form of counseling; when asked about any
history of mental health issues she simply answers no.

Alcohol/drug history
Her response to this question was the same a simple no. But given her deceased husbands
history with alcohol and her sons current involvement with drugs I am sure she is acquainted
with the effects of living with a substance abuser.
Legal Issues
The only legal issues she mentioned were those involving her estranged son.

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