Report Sample of Bio-Psycho-Social Assessment

The assessment concerns Dalia a fourteen-year-old biracial girls whose presenting issue is behavioral issues, which include argumentative behavior with authority figures, high-sexualized behavior with male peers, truancy, verbal combativeness when confronted, physical altercations with peers, irritable mood and poor concentration in class. The client being a minor comes for counseling in the company of her parents who are acting in response to a recommendation for counseling made by Dalias school. Her parents also report of her physically threatening and argumentative nature when at home which is also part of her presenting issue. The demographic information is that the client is a fourteen-year-old girl, she is born of biracial parents and therefore is of the African iris America decent. She lives with her parents in a middle-class suburb. She is the third born in a family of three and is currently the only child who lives with her parents. Her parents have been married for twenty-five years with both being away at work most of their time. Her current living situation is that she lives with her parents in a middle-class suburb.

Her birth and development history is that she was born healthy and did not experience any serious developmental issues during the initial stages of her early childhood. However, she was diagnosed with sickle cell anemia during the same developmental period and had to be hospitalized many times when she was still a child. Her health is currently stable with her last serious episode being two years ago. She seems to have had good social and psychological development because there is no indication of serious social and psychological issues she has experienced in her childhood apart from her current presenting issue. Her school and social relationships are as follows; Dalia seems like a social individual because she often interacts with other people outside her family. The interactions may be negative according to the issues that are presented especially because her school reports she has physical altercations with her peers, highly sexualized behavior with male peers while her parents report that they discovered that she and her friends were drunk in their home. Her parents also report that she was an easygoing, good-natured youngster who enjoyed singing and participating in activities with her peers and family. It shows that Dalia is not reserved but has developed various social relationships with peers. Her current behavior in school seems to be what brings Dalia for counseling because the school recommends counseling due to how she is currently behaving. The report is that she engages in argumentative behavior with authority figures at school, has physical altercations with her peers, truancy among other behavioral issues. It is an indication that her interaction with various school authority figures and peers is not okay.

She is the last born in a family of three and currently the only child living with her parents. Reports of her significant others indicate that their relationships have been okay and close-knit until her sister left where Dalia explains that her parents became distant and less available. The parents are often busy at work and therefore less available to the client. Her father is the most absent between her parents because he often leaves early for work and comes in late. It is why he is trying to compensate for being absent through letting the client do whatever she wants. Her mother is also always busy at work and therefore not as available as she should be. The client has two older siblings, a brother, and a sister. They do not often interact as the brother lives in another state and the sister is away in college. She describes her relationship with her brother as cool and with her sister as not cool. She currently has a medical issue, sickle cell anemia that is at the moment stable. She has no indication of any psychiatric problems and engages in the use of alcohol for social purposes. Therefore, she does not qualify to be an addict. There is no indication of the clients spiritual development. Her parents report that she was an easygoing, good-natured youngster who enjoyed singing and participating in activities with her peers and family. However, her social and communal engagement in various activities has changed because she is irritable towards others and will engage in altercations with her peers. She does not also engage in extracurricular activities because she views them as boring and corny. Dalia seems to be assertive because she does not let her peers bring her down. Though she will engage in arguments with them, she stands up for herself. Dalia is also sociable because she easily interacts with others and has made friends. She tries to communicate with her parents despite them being ever busy and absent. She has various resources including her parents and siblings who despite their absentia could act as significant sources of support.

Dalia faces numerous challenges including that her parents are distant and unavailable. She used to enjoy their company when her sister was around, but she complains that once the sister left the parents became busier at their work and she is often alone most of the time. Her parents do not give her enough of their time and attention, and therefore Dalia is engaging in the behavioral issues to get their attention. She also experiences loneliness because her siblings are away and thus spends most of her time alone at home. She feels less successful that her sister who her teachers always compared her to during her middle school. Her sister was bright and popular, and therefore the comparison from her teachers made her feel less important and successful that her sister. The client presents no indication of drug addiction. She, however, engages in drinking alcohol, which she owns up but is not addicted. Her drinking is at the social level. It is also an indication that she is with the wrong type of friends because she will engage in problem behaviors when in their company. She also faces a challenge due to her race. She is of the Africa Irish-American decent which means that her racial orientation is different from the contemporary American. Her parents are also of mixed races, which could pose a challenge especially in issues of acculturation. She is not sure where she needs to lean towards or identify with, in issues of culture. Her race could also mean that she may not be as comfortable in school as she should be and she could be experiencing social and psychological issues due to her race. It is, however, clear that her behavioral issues are in an attempt to seek attention which in normal cases she does not get from her parents.

The client feels neglected by the parents who are part of her social environment. Therefore, she tries to behave in a way that will attract the attention of her parents. Her peers seem to be of the wrong influence towards her because she has engaged in a couple of alcohol use instances when in their company. She has had limited interactions with her siblings as they are older than her and thus would not interact freely with them and they are also away all the time. Therefore developing the necessary bonds with them seems to be a challenge. Her school environment also seems to be unfavorable as her teachers often compared her with her older sister who was more popular and successful. The comparison affects her self-esteem and makes her feel inadequate and less successful that her sister.

The best-suited theory for dealing with the clients issues is the cognitive behavioral therapy. The approach is effective in addressing any maladaptive thoughts and behaviors the client has developed. It also helps to deal with the communication breakdown that is currently present in the family. The family systems theory is also necessary as it helps in analyzing the dynamics that exists among the family members. According to the family systems theory, it will be hard to understand people as individuals because they are part of the family. Families are emotional systems, and the subsystems who are mainly the family members will contribute to the emotional welfare of the family. However, there seems to be emotional cutoff in Dalias family. According to Titelman (2014), an emotional cutoff is where family members will respond to the anxiety present in the family through automatically shutting down their emotional connections (pg. 381). Cognitive behavior therapy in the case of Dalias family will be more effective through the incorporation of various family techniques including reframing. According to Graham and Reynolds (2013), cognitive behavioral therapy will be useful in identifying the varied perception of the family members concerning what the problem is and the best way to address it (pg. 18).

Through the assessment, it is clear that there is the issue of communication breakdown in the whole family. It is also evident that the parents do not give their daughter as much time as is necessary. Therefore, her problem behaviors are a way of seeking the attention of her parents. It is also clear that she has low-self esteem because she is easily influenced into taking alcohol. Therefore, the information will be essential in developing goals necessary for effective communication in the family. It will also ensure that Dalia gets some attention and time from her parents and it will help in the development of goals geared towards improving her self-esteem. Dalias strengths will be necessary for ensuring that the goals are accomplished. She is an open person and easily expresses herself. It means that it will be easy for her to disclose her emotions and feelings during the counseling sessions. She is also sociable and thus will easily interact with her parents during family therapy and even after counseling, it will be easy for her to identify and create meaningful friendships.

The intervention focuses on dealing with the breakdown in communication among the family members. Therefore, the most applicable technique from the family systems theory would be strategic family therapy, which focuses on dealing with communication and problem-solving pattern. Some of the techniques under the therapy include reframing which involves the use of paradoxical interventions (Graham & Reynolds, 2013 pg. 18). Reframing will also be more effective when used in a cognitive behavioral way where the clients will be trained on how to use the technique and given the assignment to work on using the technique. The ethical issue that may arise in the counseling process is confidentiality. The process involves dealing with Dalia alone as the client and doing family therapy where the parents come in. Issues are bound to arise from the sessions with Dalia, which she may not what revealed to her parents. As a counselor, it is necessary that the issues discussed between the therapist and the client remain undisclosed to any third parties. Therefore to deal with the ethical problem, it will be necessary for Dalia to be aware of instances where confidentiality will be broken including instances where the information may cause harm to her or other people or when the law requires the information. She will be aware of when confidentiality will be broken from the first session to ensure that in cases where the counselor needs to share the information there will be no resistance from Dalia.

Dealing with clients from different cultural orientations is often challenging for any therapist. The family is from different cultural backgrounds because the parents are African and Irish American. They have cultures they conform to, and Dalia has also developed a culture she identifies with. The therapist also has a cultural orientation, which is different from what the clients come with. Therefore, i...