Biopsychosocial Spiritual Assessment

The Biopsychosocial Spiritual Assessment approach is a concept that incorporates four components to analyze clients. This assessment approach provides extra information that is not in the DSM approach to provide a comprehensive assessment and diagnosis. These four components; Biological, psychological, social, and spiritual, provide a context for the issues a client is experiencing (Sommers-Flanagan & Sommers-Flanagan, 2017). This type of assessment makes use of critical thinking and is popular among mental health professionals (Basu & Ghosh, 2018). The use of the spiritual approach in this assessment is not a new concept despite facing challenges during the evolution of the mental health profession (Chi, 2018). Incorporating the religious and spiritual aspects into such examinations is crucial to ensuring respect for cultural diversities and integrity, especially in social work (Drechsler et al., 2020). Incorporating this concept is necessary for social work due to clients’ and peers’ incorporating their religious aspects during assessments.

Identifying information

The client wishes to remain anonymous; hence I refer to her as Jane. Jane is a 24-year-old Caucasian female who currently resides in 555, Texas. Jane reports she is single and has no children. Jane currently resides with her aunt and uncle. Jane lives about a mile away from the agency. The client usually uses public transportation to get about and reports that her aunt and uncle drive her to her destinations on different occasions.

Jane reports that she has been facing problems dealing with psychological problems from her teen years as a result of sexual assault from her father. She reports that the incident took place when she was sixteen years old. The reason to seek medical assistance is to help her come to terms with the issue, as it seems to be affecting some of her daily routines. The client states that the incident happened only once. Jane reports that her mother knows of the incident and her father is still in prison serving his sentence. The situation still affects Jane since she does not feel comfortable living with her mum.

The client states that her social worker gave recommendations and referred her to the agency. The client reports that her motivation to seek services is from motivation from her mum and aunt. She reports that her mother and aunt are the first people to suggest getting help or communicating to a professional about the problem. She states that she has problems talking about the situation since she feels it is embarrassing and that the feelings about the incident have been affecting her school and social life. Jane reports having been through a doctor previously before consulting help from another source (Khan et al., 2018). The client first consults a social worker in the nearby health facility, who later refers her to the agency.

The social worker identifies that the client previously consulted a medical physician diagnosing her with depression, anxiety, and PTSD and that some of the problems associated with this diagnosis are still affecting the client. The client’s family feels that she has been acting withdrawn and irritable, which concerns them and prompts them to advise her to seek professional help. The client is currently seeking assistance from a social worker in her local health unit.

Biological Assessment

The client appears calm, composed, and presents clear speech. The client is dressed in casual attire. There are no signs of hygiene neglect. The client has dark circles on her under her eyes. There are subtle signs of uneasiness manifested by fidgeting and avoiding eye contact when she speaks. The client is, however, comfortable talking about the situation.

Body appearance shows that the patient is a healthy young female who is physically fit. Jane states that she participates in athletics in her school and enjoys swimming. The client states that her appetite does not indulge in a lot of junk food but tends to skip some meals in the day. The client does not have children and has not had any miscarriages. Jane seems to have irregular sleeping patterns and problems sleeping, displaying problems associated with insomnia. The client reports that she has been experiencing cases of a decrease in energy, concentration, and constant headaches. The client also displays instances of irritability as friends and family have been complaining.

The client reports that she has had no mental or physical health problems in her early childhood. Jane states she was diagnosed with PTSD and depression at the age of 19 and did not have a history of serious medical conditions. The client is currently not taking not on the medication from the previous diagnosis. Instead, the client states to be taking over-the-counter drugs sleeping pills like Benadryl and Aleve to assist with her current sleep problems (Sudershan & Kamath, 2017). Jane is aware of her mental issues and is keen on finding help to deal with most, if not all, her situations. The client feels that she needs therapy and counseling from sources other than those in the community since she feels uncomfortable (Khan et al., 2018). Jane states that her medical health insurance is under Medicare due to her current financial status.

Jane reports she has no food allergies or nutritional issues she is aware of both currently and in the past. The client does not also face any problems with food security in her current home. She is currently not taking any prescription medication. The client does not use alcohol, tobacco, marijuana, or any other drugs. The client states that she is currently using non-prescribed sleeping medication she acquires from the local pharmacy. The client seems to be in good physical shape due to her past participation in athletics and swimming. She states that she does partake in these activities at least four times a day, even after completing high school. She, however, states that she experiences when doing her physical activities than prior experiences.

Psychological Assessment

The client is oriented to her person, place, time, and situation proving she is at the highest level of orientation (x4) (Jung et al., 2019). Jane states a history of diagnoses like severe depression anxiety from a previous doctor in a public hospital. Jane first saw her doctor when she was eighteen years old. The doctor in charge of her case first prescribed medication to deal with her depression. She reports that she has been using antidepressants like Zoloft for a significant period (Fong et al., 2017). The client reports that she did not attend any therapy despite advice from the doctor. She states that cases of insomnia and lack of appetite became severe after starting the medication (B, 2017). She reports that she stopped taking the medication after four months of use because of the severe side effects that she found uncomfortable.

The client’s second visit to a different doctor took place at 19 years after her symptoms started to reoccur, with support from her aunt (Sudershan & Kamath, 2017). She states that her doctor Mel was more thorough than the previous physician. Dr. Mel’s analysis concludes that the patient has anxiety, severe depression, and anxiety according to the client’s symptoms and thorough physical examinations. The client states that the doctor prescribed Venlafaxine to help with her depression and PTSD and recommended counseling sessions (Lapmanee et al., 2017). The client reports completing the prescription yet experiencing problems with insomnia. Jane reports not attending therapy sessions due to school and other responsibilities.

The client reports past domestic violence in the form of constant argument cases during her childhood years due to her father’s alcoholism. The client reports a history of trauma in her teenage years after the sexual assault. She reports that the incident was confidential until she was eighteen. The client reports having nightmares, leading to early cases of depression (Wilson et al., 2017). She also reports decreasing in appetite and a decrease in body weight during her teen years. The client reports cases of experiencing previous issues of fear, hopelessness and feeling disconnected from her friends and family due to the assault incident. The client has reported on sexual abuse history. There is also evidence of neglect from the family members since none of them notice any psychological disorders until later years of her adolescence. She has no childhood welfare history. Jane does not have prior cases of substance abuse but reports early cases of being diagnosed with depression, PTSD, and anxiety disorders (Wilson et al., 2017).

The client states that her father has had a prior history of depression, PTSD, and alcohol abuse for years. She does is not aware of when her father was diagnosed with depression but stated that he has been battling with the issues for years. The client also reports that her father cut short his medication around ten years ago and currently does not have knowledge of his medical tendencies. She also reports that her mother and two sisters do not display any current or past evidence of genetic or psychiatric problems. Jane also reports that past relatives on her father’s side also have battled cases of depression with minimal medical and other interventions (McIntosh et al., 2019). She states that her father was exposed to physical abuse from his father as a child and adolescent (Adams et al., 2018). Her mother, on the other hand, comes from a stable family raised by her single father and three elder siblings. Jane appears to be a strong, self-driven, and intellectual young lady, although She struggles with her anxiety and depression.

Social Assessment

Jane is a bright young lady who completed her high school level at Bridge high school, which is located near her home area. She reports having participated in volunteer programs in the local health facility during most of her junior years and some part of her senior year. She is currently not in school but has plans f proceed with her education in the future. She currently works as a librarian’s assistant in the town’s local library. She is a member of the Hope Church in her local community and loves to participate in their volunteer programs like rounding up donations visiting, and helping out in local children’s homes.

Jane is the firstborn in her family and has two other siblings, a brother and a sister. Her father and mother are currently divorced due after her mother found out about the assault case. Her mother works as a vendor in the town’s supermarket while her siblings attend school at Smart Elementary. Her father is currently in prison, serving his sentence for sexual assault. Jane still maintains contact with her family and takes time to visit her mother and siblings and states. She states that she does not wish to reconnect with her father not mend their relationship. She states that her relationship with her aunt and family is great, and they treat her like their own daughter. Jane is still close to her friends from high school. The client has does not have a current or past romantic relationship but is willing to take chances in exploring the idea (O’Callaghan et al., 2018).

The client’s main source of income is from her job as a librarian’s assistant. Jane is a grown-up according to the state, although her aunt and uncle act as her guardians. The client’s mother held the power of attorney when she was still a minor in the eyes of the state. The client is in the military, not a veteran, and shows no interest in enrolling in the program in the future. She, however, states that her grandfather, from her father’s side, was a part of the arm in the past and holds the position of lieutenant. Jane still wishes to continue her studies and attain a college degree in Sociology. She currently lives with her aunt and uncle, who play a part in sorting her finances before she is stable enough to live alone. The client reports that she has no current or past legal issues. Jane explains that her aunt and uncle’s two children do not live with them as they study in colleges far from their homes. The client has no problems with immigration as she is legally a member of the state by birth. Jane reports no current human rights or social justice issues. Jane is a cheerful individual who is determined to make the best of her life situation, has stable relationships with her family and friends, but is reluctant to get into romantic relationships (O’Callaghan et al., 2018).

Spiritual Assessment

Jane has identified as a member of the Christianity religion since birth. The client makes to attends church every Sunday and participates in church events and projects. Jane’s beliefs teach that each individual has a personal relationship with the higher power, and they all have a duty to maintain his wishes of love to all human beings. The client participates in religious and spiritual practices like prayer and meditation to connect to the higher power.

Jane displays strong faith and hopes with her determination to proceed with her life despite her traumatizing past. She states she still struggles with forgiveness, especially when it comes to her father but knows that she will eventually attain peace of mind. Approaching the client’s situation requires that intervention methods coincide with her faith. It is important not to judge the patient’s religion and refrain from imposing one’s beliefs. Provide clients with an atmosphere where they feel safe and free from judgment. Encourage to focus on appropriate teachings from the faith. It is also important to encourage the client to also seek help and advice from their religious mentors or leaders.

References

Adams, J., Mrug, S., & Knight, D. C. (2018). Characteristics of child physical and sexual abuse as predictors of psychopathology. Child Abuse & Neglect, 86, 167-177. https://doi.org/10.1016/j.chiabu.2018.09.019

B, S. (2017). Antidepressants: Mechanism of action, toxicity, and possible amelioration. Journal of Applied Biotechnology & Bioengineering, 3(5). https://doi.org/10.15406/jabb.2017.03.00082

Basu, D., & Ghosh, A. (2018). Substance use and other addictive disorders in international classification of diseases-11, and their relationship with diagnostic and statistical manual-5 and international classification of diseases-10. Indian Journal of Social Psychiatry, 34(5), 54. https://doi.org/10.4103/ijsp.ijsp_83_17

Chi, M. Y. E. (2018). Faith-inspired praxis of love: A framework for helping. Journal of Religion & Spirituality in Social Work: Social Thought, 37(4), 414-435. https://doi.org/10.1080/15426432.2018.1511389

Darrell, L., & Rich, T. (2017). Faith and field: The ethical inclusion of spirituality within social work pedagogy. Field Educator, 7(1), 17-157

Fong, P. P., Bury, T. B., Donovan, E. E., Lambert, O. J., Palmucci, J. R., & Adamczak, S. K. (2017). Exposure to SSRI-type antidepressants increases righting time in the marine snail Ilyanassa obsolete. Environmental Science and Pollution Research, 24(1), 725-731. https://doi.org/10.1007/s11356-016-7855-y

Hunt, J. (2014). Bio-Psycho-Social-Spiritual Assessment? Teaching the Skill of Spiritual Assessment. Social Work & Christianity, 41(4)

Jung, H., Daneault, J., Lee, H., Kim, K., Kim, B., Park, S., Ryu, T., Kim, Y., & Lee, S. I. (2019). Remote assessment of cognitive impairment level based on serious mobile game performance: An initial proof of concept. IEEE Journal of Biomedical and Health Informatics, 23(3), 1269-1277. https://doi.org/10.1109/jbhi.2019.2893897

Khan, S., Hirsch, J., Wamboldt, A., & Mellins, C. (2018). “I didn’t want to be ‘That girl’”: The social risks of labeling, telling, and reporting sexual assault. Sociological Science, 5, 432-460. https://doi.org/10.15195/v5.a19

Lapmanee, S., Charoenphandhu, J., Teerapornpuntakit, J., Krishnamra, N., & Charoenphandhu, N. (2017). Agomelatine, Venlafaxine, and running exercise effectively prevent anxiety- and depression-like behaviors and memory impairment in restraint stressed rats. PLOS ONE, 12(11), e0187671. https://doi.org/10.1371/journal.pone.0187671

McIntosh, A., Shen, X., Howard, D., Adams, M., Clarke, T., Whalley, H., Coleman, J., Wray, N., Lewis, C., Sullivan, P., & Breen, G. (2019). Uncovering the genetic architecture of major depression and its phenome-wide effects. European Neuropsychopharmacology, 29, S52-S53. https://doi.org/10.1016/j.euroneuro.2019.07.108

O’Callaghan, E., Shepp, V., Ullman, S. E., & Kirkner, A. (2018). Navigating sex and sexuality after sexual assault: A qualitative study of survivors and informal support providers. The Journal of Sex Research, 56(8), 1045-1057. https://doi.org/10.1080/00224499.2018.1506731

Sudershan, B., & Kamath, A. (2017). Over-the-counter medications containing diphenhydramine and doxylamine used by older adults to improve sleep, a letter. International Journal of Clinical Pharmacy, 39(4), 627-628. https://doi.org/10.1007/s11096-017-0500-0

Wilson, L. C., Miller, K. E., Leheney, E. K., Ballman, A. D., & Scarpa, A. (2017). Examining the psychological effect of rape acknowledgment: The interaction of acknowledgment status and ambivalent sexism. Journal of Clinical Psychology, 73(7), 864-878. https://doi.org/10.1002/jclp.22379

Biopsychosocial Spiritual Assessment

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