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Client Biopsychosocialspiritual Assessment

Barkley (2019) asserts that a bio-psychosocial spiritual assessment is conducted at the start of mental health treatment, often as part of the intake stage. The assessment includes various questions that clients are asked to respond to genuinely. Due to its complex nature, it might take longer to carry it out, unlike a more traditional therapy intake evaluation. Whilst a bio-psychosocial spiritual assessment can be conducted as part of a more comprehensive examination, it is often performed to address a particular presenting issue (Burns et al., 2019). This assignment aims to conduct a structured interview to gather important assessment data concerning a 32-year-old client with a mental issue. The interview was conducted at her home. The data gathered for the assessment include major physical and psychological strengths and issues, social strengths and issues, and spiritual affiliations, including any strengths and issues. Each data area was collected separately; however, historically, each is interrelated.

Identifying Information

  • Demographic information

Miss Jean Pollock is a 32-year-old single unmarried African American woman who gave up her two children to the child welfare services for placement for being unable to carter for their needs. Miss Pollock lives in a shared living arrangement located within an area where most minority communities reside. Miss Pollock hopes to get her children back and raise them by herself despite the present involvement of child welfare services. She plans on doing this after getting a good job and a better place to stay because the neighborhood she lives in is not safe; it is toxic, as she explained.

  • Referral information

A worker referred Miss Pollock from child welfare following a recommendation of the Parental Capacity Assessment made due to the requirement for counseling. Child welfare believes that counseling will help the mother of two struggling in her life resolve her problems. The interest also considers that a counselor may assist Miss Pollock in getting back on their feet and feel empowered and stronger than ever. According to Stark & Mills (2020), this will assist her in letting go of what has happened to her in the past and starting over without feeling guilty.

  • Data sources used in writing this assessment

Child welfare was engaged because of serious problems with Miss Pollock’s lifestyle, including several years of work in prostitution, interaction with people with violent and criminal characters, and severe volatility. Miss Pollock resented child welfare involvement but agreed to the suggestion of parental capacity evaluation to get counseling to deal with her issues.

Presenting Problem

  • Description of the problem and situation

Answering while staring at the floor, Miss Pollock explains that she has been overwhelmed with life, especially taking care of her children, yet has no proper work to cater to their needs. She states, “I had my children at a during my teenage hood but their father, my high school sweetheart, got a sentence of thirty years after being found guilty of robbery with violence.” She explains that she is a school dropout; thus, it difficult to find a good job. With tears in her eyes, she says, “my life is just all over the place, especially after the death of my mother who was my only family and support system which has worsened my situation…., am just overwhelmed.” Miss Pollock also explained that she feels angry at everything; she thinks she is not good enough and is a disappointment to herself and her children. She also feels empty inside since she has no close people to talk to due to fear of being rebuked based on the nature of her job. She also reveals that everyone around her judges her for being a sex worker. The only coping mechanism she is left with is acting tough, using alcohol and marijuana to numb her feelings.

  • Other persons involved in the problem

Miss Pollock’s children are involved in the problem but have been taken by the child service welfare for safety since they lacked proper care. The child welfare worker explained that the children when they were living with their mother before being taken away, mentioned that she used to be aggressive towards them and would shout at them at any slight provocation. Recently, serious partner violence was noted by her housemates with the men she gets intimate with. They also explained that she is a resistant person who refuses to be talked to even when being advised about her character.

  • Past experiences related to the current difficulty

Miss Pollock denies any of these behavioral patterns in the past and states that the difficulty began after her husband got arrested, her mother’s death, and lacking a proper job to enable her carter for her and the needs of her children.

Background history

  • Developmental history

Miss Pollock was raised by her single mother but has no siblings. After delivering the first child, who is now nine years old, she moved in with her currently-imprisoned boyfriend, and in the process, after two years, she got pregnant with the second child, who is now seven years old; their family has no history of mental illness from her narration and medical records.

  • Family background

Miss Pollock was seven when they moved as immigrants to the country with her mother and recalls her mother doing odd jobs to sustain them. When asked about her father, she looked distant in my eyes and responded, “He does not exist, and that is the way it is.” She revealed to have three to four elder cousins who live in the city but have never seen nor bothered to look for them because they have never been close. Her perspectives about family are that it socializes children, offers emotional and practical support for its members, assists in regulating sexual activity and reproduction, and offers a social identity. She also ascertained that family might be a source of conflicts, comprising physical violence and emotional cruelty and that social class impacts the anticipations partners have about their relationships and of one another.

Intimate relationship history

Miss Pollock moved in with her boyfriend after she got pregnant with their first child. Even though her boyfriend was dearly devoted to the family to the extent of doing anything for them, he started being verbally and physically abusive towards her after having their second child, though once in a while, as she stated.

Educational or vocational training

Miss Pollock is a high school dropout who failed to finish her secondary education due to early pregnancy and lack of interest in education.

Employment history

Miss Pollock is a sex worker and says it has been difficult for her to get a proper job due to her education level. She disclosed having sold drugs at some point in her life but stopped for fear of being involved with law enforcement.

Military history

Miss Pollock has no military history.

Use and abuse of alcohol or drugs

Miss Pollock explained that she has never heard of any substance abuse cases in her family and thinks she is the first one. However, she states that her boyfriend introduced her to alcohol and marijuana, which she liked due to the feeling she got after using the drugs. She also highlighted that the nature of her job and the problems she undergoes could not be faced with a sober mind. She uses alcohol and marijuana to mask her emotions.

Medical history

There is no record of previous mental health problems and treatment, hospitalizations,

the outcome of treatment, and family mental health issues in this case.

Life events

Miss Pollock’s mother died of heart complications a few months after her boyfriend was incarcerated and indicated no significant life achievements other than having two kids whom she feels are a let-down to them.

Cultural background

As mentioned earlier, Miss Pollock is African American and claims to originate from West Africa. She experiences discrimination and oppression due to her ethnicity and is always called insulting names. The impact of migration on Miss Pollock has been severe, making it difficult for her to fit in. She also reveals that her mother was denied a good job despite her skills because she was an immigrant, and this made their lives very difficult when growing up; that is why she despises education and thus decided to discontinue her studies and move in with her boyfriend thinking it was the better option.


Miss Pollock is a Christian but not spiritual because she says God could not have allowed her to suffer if He existed. She also said that it is of no use to be a staunch believer due to the nature of her work; she sees herself as a sinner and that even the church would not want to associate with her unless she moved to another country began her life afresh.


  • The key issue or problem from the client’s perspective

Miss Pollock started seeing that as a mother, she profoundly values pro-social norms for her children, but as a poor woman, she has repeatedly not observed social norms in not perceiving herself as a citizen invested in and validated by the society’s general culture.

  • The social work internist perspective

From a social work internist perspective, it can be asserted that Miss Pollock has Borderline Personality Disorder, which, according to Vonmoos et al. (2019), is under Cluster B personality disorders. Because of the condition, she is struggling with renegotiating her rightful place as a mother, woman, and citizen in this culture. Her personality traits have caused her current situation, comprising matters of dependency, insecurity, antisocial, and narcissistic behaviors. Additionally, she has trends of externalizing responsibility for poor decisions or being overwhelmed with guilt.

  • Client’s effective functioning

Miss Pollock resorts to violence, hostility, abuse of alcohol and marijuana, continued anger, and acting tough to defend herself and externalize responsibility for her actions. She has very strong emotions, mood swings, and feelings that she cannot deal with. She also feels anxious and distressed most of the time and is having issues with how she sees herself and her identity. Even though she denies suicidal ideation, she uses marijuana and alcohol to deal with her feelings. As a result, this has impacted her relationships with those around her.

  • Contributing factors

The main factor contributing to Miss Pollock’s problems is culture, which is more than a constituent of stressful life contexts; secondly, her family structure in reconstitution increased family breakdown and the small size of her family.

  • Factors that can help the client

If Miss Pollock has trouble talking to other people about her problems, she can be helped by being given a journal to write about her observations of ideas in her thoughts, history, and behavioral patterns; a very empowering process.

  • Client’s motivation and potential to benefit from intervention

Miss Pollock hopes to be able to heal, manage her personality, interact with people well, become a good mother to her kids, get a decent job and possibly change her environment.

  • Technology integration

Anderson (2019) indicates that Technology Assisted Therapy can be regarded as any technology therapy that can comprise modes such as videoconferencing or Skype, online support groups, text messaging or other media devices. As technology

becomes more impactful in society, it only makes sense that it can be integrated into the clinical social work field and therapy sessions. Therefore, in this case, online support groups can be used as a mediating force to assist in extending in-person sessions for Miss Pollock.


  • Short-term goal

To overcome how she perceives herself, Miss Pollock is advised to find more purpose in life by building better relationships, understanding and tolerating the effect of issues linked to her personality, and learning how to understand and live with herself.

  • Long-term goal

Miss Pollock has a personality disorder because of her husband being imprisoned, her mother dying, having no stable job, and her children being taken to Child welfare services, thus feeling alone. She hates herself, hates what she does for a living, sees herself as a let-down to her children, feels overwhelmed with life, abuses drugs as a coping mechanism, has a problem opening up, and does not relate with people well. Therefore, Cognitive Behavioral Therapy (CBT) is recommended because it encompasses evaluation, resulting in shared goals for transformation, but not found upon the type of false equality which overlooks subsisting power dynamics between a paid; often well-paid professional and the client; usually low income and powerless (Stormshak & Dishion, 2020). Because it is vital to see Miss Pollock get services as a psychological and emotional being and as an intellectual individual, CBT will engage her in the realm of ideas and the intellectual exploration of her experience in the society she lives in. What is being implied is that “holistic” is a wider aspect that is not usually used in counseling people with personality disorders (Ohrt et al., 2018). However, when used comprehensively or unidimensionally, it may be very empowering by relieving the client of any responsibility for their decisions in the past and their agency for the future.

  • How to include technology in the intervention plan

Technology can be integrated into the intervention plan by creating an online group to connect other individuals with problems related to Miss Pollock’s. This is a good strategy to bring them together and help her feel comfortable and that she is not the only one undergoing such problems. According to McLaughlin (2018), creating an online support group provides a safe place for people in therapy. This will enable Miss Pollock to obtain practical, constructive, and helpful information. She will benefit from encouragement and learn more about coping with her issues using shared experiences. Hearing from others undergoing the same problems will also make her feel less alone in her struggles.


Conclusively, we are currently living in a very individualistic society with people experiencing extreme alienation and societal segregation. If individualism is part of the issue and at the center of antisocial and self-destructive traits, then interventions used by counselors should challenge individualistic patterns by re-interpreting themselves and their clients in the collective and societal realm.


Anderson, L. B. (2019). The Use of Technology-Assisted Methods in Therapy: Clinical Social Workers’ Perspectives. Retrieved from

Barkley, J. (2019). Biopsychosocial Assessment: Why the biopsycho and rarely the social? J Can Acad Child Adolesc Psychiatry. 18(4):344-7. PMID: 19881945; PMCID: PMC2765389.

Burns, A., Dannecker, E., & Austin, M. J. (2019). Revisiting the biological perspective in the use of biopsychosocial assessments in social work. Journal of Human Behavior in the Social Environment, 29(2), 177-194.

McLaughlin, C. (2018). The Child, The School, Counselling and Psychotherapy.

Ohrt, J. H., Clarke, P. B., & Conley, A. H. (2018). Wellness counseling: A holistic approach to prevention and intervention.

Stark, M. D., & Mills, D. (2020). The need for counseling skills in student affairs. College Student Affairs Journal, 38(2), 113-125.

Stormshak, E., & A., Dishion, T. J. (2020). An Ecological Approach to Child and Family Clinical and Counseling Psychology. Clinical Child and Family Psychology Review, Vol. 5, No. 3

Vonmoos, M., Eisenegger, C., Bosch, O. G., Preller, K. H., Hulka, L. M., Baumgartner, M., … & Quednow, B. B. (2019). Improvement of emotional empathy and cluster B personality disorder symptoms associated with decreased cocaine use severity. Frontiers in psychiatry, 10, 213.


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