Biopsychosocial Assessment and the Mental Status Examination

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Part A: Basic Information

Identifying information

The client is a 27-year-old Caucasian female. She is currently unemployed, although actively searching for employment. She has a daughter, with whom they used to live with her boyfriend Sean. However, Alex chose to leave her house with her daughter in order to get away from Maddy’s father, Sean, who is an alcoholic.

Referral

Alex was referred by the management of a shelter where she had gone to seek assistance. Alex was seeking a place for her daughter to be accommodated as she tried to figure out how she could provide for herself and her daughter after leaving her alcoholic husband.

Presenting problem

Alex has presented with relationship challenges. She feels that her relationship with Sean, whom she cohabits with is toxic and that it puts her daughter at risk. According to Alex, Sean frequently drinks alcohol, under the influence of which, he gets violent. Although he has never hit her or his daughter, Maddy, he has thrown items at her including glass objects which end up getting shuttered against the wall and littering the floor. Although it had happened for a while, Alex decided to leave the house when it became apparent that Maddy was not growing up in a healthy environment. While she was living with Sean, he provided for the bills and utilities. She now had the challenge of finding a job that she could use to sustain Maddy.

Sources of Data

The referring agency provided much of the preliminary information about the client. However, for each fact that was reported by the referring agency, the client was asked to confirm during interviews.

General Description of Client

During a presentation for the biopsychosocial assessment and the mental status examination, the client was distressed. Her anxiety seemed to be caused by running or hiding from someone that the client feared would eventually catch up with them. Even though she was running from Maddy’s father, she was protective of his behavior. She tried to make it apparent that the relationship was toxic in terms of creating an unhealthy environment for Maddy. However, she was very clear to mention that Sean was a good dad that was loved by Maddy and that she did not think that Sean was likely to ever physically hurt them.

Part B: Background and Current Functioning

Family Composition and Background

Alex is part of a nuclear family, composed of herself, her daughter Maddy, and her husband Sean. Maddy is 2 years, which means she is totally dependent on her parents for her all-around well-being, including psychological well-being. Alex’s husband owns the trailer that they used to reside in. Sean was also responsible for taking care of the family’s needs since Alex had not been currently employed. However, Sean has a drinking problem whereby he becomes violent after consuming alcohol. Alex has no siblings and the only family member whom she keeps in touch with is her mother. However, Alex and her mother have never had a good relationship. Alex’s mother has a diagnosable mental health condition but she has not embraced treatment or taken any medication.

Educational Background

Alex’s education life was not smooth. Even though she completed her high school education, she frequently transferred to new schools. After completing his high school education, Alex was eligible to join college. However, she did not enter college and instead preferred looking for employment as she sought freedom and independence from her mother.

Employment and Vocational Skills

The client, Alex, is currently unemployed. However, she has tried house cleaning jobs in the past as a maid. Earlier on before she got pregnant with Maddy, she used to do waitressing in a restaurant.

Religious/Spiritual Involvement

The client has not disclosed her identity with any religion or spiritual practices that she engages in. Since religion is an important aspect of culture, in its absence, other personal beliefs and attitudes influence her biopsychosocial wellbeing.

Military Service History

The client was never in the military.

Physical Functioning, Health Conditions, and Medical Background

The client seemed a little bit pale, weak, and distressed. Her presenting problem explained the distress. The paleness and weakness were explained by the client as a result of poor feeding. Alex did not report having any underlying health conditions. However, she noted a genetic predisposition to mental health conditions.

Substance Abuse, Psychological, Psychiatric Functioning, and Background

Alex did not report any history of having psychiatric problems. Although she consumes beer, it is on a few occasions and only to a limited degree. Alex has never considered herself an alcoholic. In terms of her psychological well-being, Alex has suffered an unhealthy relationship. Her husband, Sean, is an alcoholic who gets violent when he is drunk. Sean punches things when he is drunk as well as throws objects against the wall.

Social Community and Recreational Activities

The client does not have a good support system. Her mother has an unstable life which makes her unable to provide the support that her daughter needs. However, Alex does have a friend whom she can turn to when she needs help. When her friend cannot provide help, Alex does not have anyone else who can provide her with social support. IN terms of her hobbies, Alex enjoys writing, reading, and narrating in front of crowds.

Basic Life Necessities

Due to her unemployment status of Alex, she is currently finding it very hard to afford basic life necessities such as housing and food. As a result, she has to turn for help from a domestic violence shelter. As Maddy’s mother, Alex feels responsible for her wellbeing. She, therefore, believes that Maddy must be under custody. However, her husband Sean has petitioned to be granted full custody of Maddy. Since Maddy is Alex’s strongest motivation for living, she urgently requires legal representation in the litigation process.

Current Legal Concerns/History of Incarceration

The client does not have a history of the previous incarceration. The client is a documented citizen currently pursuing separation from her husband.

Other Environmental Psychological Factors

The client’s condition may be exaggerated as a result of her gender. For example, it is clear that Sean believes that a woman should be controlled and that they cannot support themselves without getting help from men. Similarly, the fact that she is from a low socioeconomic class, she receives bad treatment from the high-class citizens.

Client Strengths, Capacities, and Resources

The client is motivated by her daughter. She knows that she has to do everything that she can in order to provide for her daughter. This makes her consider seeking help as well as trying to resolve the situation on her own. She has even tried to look for employment in order to cater to her needs and those of her daughter.

Reference

BIBLIOGRAPHY l 1033 Maid. Dir. Smith Metzler Molly. Netflix. 2021. TV Series.