Running head: BIOPSYCHOSOCIAL-SPIRITUAL CRITICIAL ANALYSIS

Bio-Psycho-Social
Crystal McMillon
Wayne State University

Bio-Psycho-Social

BIOPSYCHOSOCIAL-SPIRITUAL CRITICIAL ANALYSIS

Referral Statement
Dominique Smith (pseudonym) comes from an impoverished area with limited
resources. She is currently facing a myriad of challenges due to the sexual assault she
experienced during her adolescence: high levels of anxiety (frequent reoccurring thoughts
and visions of her sexual assault), which have lead to self-destructing behavior with the
abuse of alcohol (drinking an average of 4 days a week), complaints of depression
(insomnia, sleeping an average of 4-5hrs a night and feelings of sadness and emptiness),
and relationship issues (issues with trust and commitment). She is now enrolled in
National Counsel on Alcoholism and Drug Dependency (NCADD) treatment program to
assist her in the healing process along with her issues of substance abuse, upon her
mothers request. Client has been enrolled in this treatment program since 8/5/2015. She
does believe that a more serious, committed program is needed in order to lead her down
the right path of healing and recovery, which is why she seek services here at this
SASHA Center on 10/12/2015. Per client I would like to feel normal for once in my
life, by addressing my trauma with outpatient services that you offer.
Identifying Information
The clients name is Dominique Smith. Her date of birth is 09/06/1994 she was
born in Detroit, Michigan. She is an African-American, who is currently 21 years of age.
Client is Baptist. She received her high school diploma from Belleville High School in
2011. She is currently employed at a local strip club as a waitress. She is single, and was
living with her mother at XXXXX Riverview St, Detroit, MI until she was put out due to
her issues with substance abuse. She currently has no permanent address, and is living

BIOPSYCHOSOCIAL-SPIRITUAL CRITICIAL ANALYSIS

with various friends. Her mother stated that she wouldnt allow her to return home until
she seeks help.
Problem Identification and History
A. Presenting Problem
Dominique comes from an impoverished area with limited resources. She is
currently facing a myriad of challenges due to the sexual assault she experienced at the
age of 18. She is currently homeless, due to her issues at home, which stem from her
challenges with substance abuse. Dominique currently has been living with different
friends. She is currently enrolled in NCADD treatment program for her substance abuse
issues. Client states that she often has repeated thoughts of the assault and nightmares.
Client also stated that she likes to drink to help her cope. She states that when she drinks
it numbs the pain and suppresses her memory. Client states that her drinking has become
a problem in her relationship with her mother, which is why she is seeking help. She feels
as though she is depressed, but has never been diagnosed or received any prior help
regarding her issues. These issues have been ongoing for three years since the time of her
sexual assault.

B. History of Problem
The client reported her substance abuse as I only drinking socially, my mother is
just worried. The patient only made one attempt to the solution, which is the outpatient
treatment therapy at NCADD. The history of her sexual abuse problem has been
occurring for three years. Client states At time I feel worthless, especially when I realize
the moments of my sexual assault, but I have never contemplated suicide.

BIOPSYCHOSOCIAL-SPIRITUAL CRITICIAL ANALYSIS

IV. Biological Factors and Functioning

Client is about 55 and weights about 145. Client appears casually dressed, neatly
groomed and is cooperative. She is calm and there is no evidence of tremors, tics or
muscle spasms. Her affect is appropriate to the conversation, and her mood is slightly
depressed. Speech is soft. Her thoughts flow logically and are organized with no
perseverations, loose associations or thought blocking. There is no evidence of
hallucinations or delusions. She is oriented to time, place and person. She does place
devaluation on herself that is not supported by her situation.
Client is a bisexual; she lost her virginity at age 15. She began dating seriously at
age 17. She enjoys sex sometimes, but still faces a myriad of challenges due to her sexual
assault. She stated that when she does orgasm they are normal, but there are a lot of
times during sexual intercourse that she does not orgasm. Her current sexual partner is
her male partner of two months. She stated that she has relationship issues due to trust
issues and changes sexual partners frequently because of this. Her and he sexual partners
do not always use contraceptives and she is currently not taking birth control pills.
Dominique has contracted gonorrhea and trichomoniasis from past sexual relations and
was treated for these sexually transmitted diseases at a local free clinic.

BIOPSYCHOSOCIAL-SPIRITUAL CRITICIAL ANALYSIS

V. Psychological Factors and Functioning

Dominique is very intelligent she is just battling the aftermath of her sexual assault. When
Dominique becomes overwhelmed or stressed she shuts down instead of discussing the issue at
hand. Resulting in the avoidance of people. Dominique has frequent nightmares about being
sexually abused, causing her to sleep a total of 4-5 hours a night. Client also reported feelings of
sadness and emptiness when these flashbacks occur.

VI. Social Factors and Transitions

A) Client is open to outside help. She is currently enrolled in a treatment program for
substance abuse. She states that she enjoys the sessions, even though she doesnt feel her
issue is not bad, she still learns a lot about others and how they handle similar problems
as hers. Client has well to fair relationships with her immediate family and did not report any
relationship with extended family. Client did mention that she wishes that her and her mother
were closer, but feels that once she can receive the proper healing, that it would be the first
step in their relationship. Client stated that before her sexual assault her and her parents
where really close. Client states that her and her father have a good relationship, but she
doesnt see him often due to his employment. Client has been out of high school for five and
has not furthered her education. Client stated that she remains close to a few friends from
high school, but most of her friends are her co-workers. Clients work may not be supportive
due to thats where she does majority of her drinking. Client is Baptist and does attend
church. In addition, she stated that she has good relationships with the people in her
neighborhood, considering she has lived their majority of her life. Client also remains social

BIOPSYCHOSOCIAL-SPIRITUAL CRITICIAL ANALYSIS

via social media. Client indicated that she loves Instagram, Snapchat and Twitter. Client
stated Twitter is my favorite social site because it provides me with an outlet, its like my
online diary.
B) Client is verbal and able to communicate her feelings. When it comes to commitment
and trust client has issues in this department. Dominique stated that she might meet
someone and be very playful and sexually active, but then shut down sexually as the
relationship proceeds and deepens. Since a close friend sexually assaulted Dominique she
has issues with trust especially when it comes to her emotions. She indicated that the
closer she becomes to someone, no matter what the trust issue always resurfaces. She did
state that at times she has limited ability to feel sexual pleasure, specifically orgasm,
which leads to he promiscuity. She stated that her other relationships are fine, trust only
comes in to play when its dealing with someone that she is dating.
C) Client reported her father, Carlos is 45 years old and her mother, and Rhonda is 40 years
old. She reported her parents got a divorce when she was 16. She reported that she has a good
relationship with his father and reported her relationship with his mother is an emotional
rollercoaster, but knows that her behaviors are the cause. She reported that her parents are
very supportive, but believes her mother is worried that she will go down the wrong path if
she does change some of her ways. Client denied having any siblings or children. Client does
not report any family history of mental illness. Client reports that only family history of
addiction is his father who used to be an alcoholic. Client reports that her dad has been sober
for three years.

BIOPSYCHOSOCIAL-SPIRITUAL CRITICIAL ANALYSIS

D) Client received her high school diploma. She indicated that while in high school she had a
great relationship with her peers and teachers. Her favorite subjects were English and
Science. Client also stated that she does plan to attend college, but knows at this moment she
isnt mentally prepared. Client is unsure of what she wants to major in, which is another
reason why she hasnt enrolled in college yet.
E) Client reported that she has been employed at the strip club since she was 18. She indicted
that she loves her job and the money is great. Client didnt disclose her income.

VII. Cultural Factors and Transitions

A) Cultural factors that impact the client are her religious beliefs. She indicated that praying
and going to church were helpful when she felt sad. The client believes that her religious
or spiritual beliefs will only have a positive impact on her treatment here at SASHA
Center.
B) She also indicated her disabilities include: high levels of anxiety, substance
abuse, and relationship issues
C) Client does recognize that she needs help, not only for her self but those close to her
like her mother and current partner.
D) The patients primary language is English. The patient appears to have Post
Traumatic Stress Disorder due to reoccurring thoughts of the assault and nightmares
and high levels of anxiety, like insomnia. Client reports many restless nights.

BIOPSYCHOSOCIAL-SPIRITUAL CRITICIAL ANALYSIS

VIII. Substance Use

A) Client does not use prescription drugs not even recreationally.
B) Client drinks alcohol heavily; she began drinking at the age of 19. She states that
due to her employment she drinks a lot because it is accessible. Client believes that
she does not have a problem when it comes to alcohol, just enjoys to drink,
especially while at work. Client reported that she drink 4 days a week.
C) Client does report to drinking alone, but only when she is overwhelmed with her
reoccurring thoughts of her sexual assault. Reports that she may drink fours days out
the week, but its more social than not.
D. Client has no past use of alcohol or drugs.
E) Client report no personal, legal or employment problems related to substance
abuse.
G) Family history of abuse comes from her father, who has now been in recovery for
2 years.

IX. Other Significant Factors

A. Client has no history of legal involvement and no pending legal action.
B. Client has no military history and does not plan to join the military.
X. Biopsychosocial Diagnostic Statement

BIOPSYCHOSOCIAL-SPIRITUAL CRITICIAL ANALYSIS

Dominique Smith is a 21 year-old, single, African American. She had a

traumatic emotional experience to led symptoms: high levels of anxiety (frequent
reoccurring thoughts and visions of her sexual assault), which have lead to selfdestructing behavior with the abuse of alcohol (drinking an average of 4 days a
week), complaints of depression (insomnia, sleeping an average of 4-5hrs a night and
feelings of sadness and emptiness), and relationship issues (issues with trust and
commitment).
Client has history of sexual abuse which maybe of significance to her current
mood status at this time in her life. Client does have great coping skills: social media
and church. Client demonstrates motivation and hope for change. The key issues
from the client perspective are those stemming from her sexual assault that is listed
above.
XI. SPECIFY A DIAGNOSIS
The client suffers from Post Traumatic Stress Disorder (PTSD). Client has
been diagnosed since August of 2015 with PTSD. Client directly experienced a
traumatic event of sexual assault, which has caused clinically significant distress or
impairment in her social interactions. Symptoms include: re-experiencing,
avoidance, negative cognition of self, effecting mood and arousal. Client reexperiences the spontaneous memories of the traumatic event, recurrent dreams
related to it, flashbacks or other intense or prolonged psychological distress.
Avoidance refers to distressing memories, thoughts, feelings or external reminders of
the event. Negative cognitions and mood represent myriad feelings, from the

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10

persistent and distorted sense of blame of self or others. Finally, arousal is marked by
aggressive, reckless or self-destructive behavior, sleep disturbances, hypervigilance
or related problems.
Social workers Intervention
Survivors of sexual abuse face a myriad of long term effects throughout ones life:
negative psychological and interpersonal effects that are both long term and short term. If a
victim does not receive the proper help it only makes matters worst: by internalizing the
problem or by self-blame. By victims not receiving proper help they only increase their risk
of symptoms: depression, anxiety, posttraumatic stress disorder, substance abuse, attachment
disorders, re-victimization. Victims of sexual abuse also have future relationship problems,
due to lack of trust.
There are a numerous of different treatment methods for those who have been assaulted,
and overall it boils down to what works best for that particular individual. Cognitive Behavior

Therapy (CBT) is the current invention that is being used at SASHA. This intervention
aims to reduce the trauma symptoms among the survivors of sexual abuse . Furthermore, is

beneficial for both Dominique and future generations of this population. CBT has helped
Dominique complete goals: coping with symptoms of sexually assaulted victims and
issues with substance abuse or addiction. According to research cognitive behavior
approaches come from four theories: associative learning, the effect of the environment on
patterns of behavior, learning by imitation, and the impact of thought patterns on feelings and
behavior (Macdonald, Higgins, Ramchandani, Valentine, Bronger, Klein, ODaniel, Pickering,
Rademaker, Richardson & Taylor 2012). Results show that negative symptoms associated with

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sexual abuse: depression, post-traumatic stress, anxiety, and behavior issues are reduced
significantly after CBT.

CBT has the most effectiveness on this population with a significant decrease in their
emotional and behavioral problems. Additionally, CBT can help build interpersonal relationships
due to the interaction within therapy. Overall, Cognitive-Behavioral Therapy displays that people
can have a healthier emotional and relational strength by engaging in CBT therapy.

Dominique is also seeking treatment for substance abuse at National Council on

Alcoholism and Drug Dependency (NCADD). NCADD uses a Cognitive Behavior
Therapy model to help clients learn methods to avoid substance use and abuse. CBT is a
short-term, focused approach to helping addicted individuals become abstinent from
drugs and alcohol. CBT has been shown to be the most effective method of counseling
individuals who suffer from addiction (NCADD, 2012). According to a recent study,
CBT models are among the most extensively evaluated interventions for alcohol- or
illicit-drug-use disorder. CBT treatment for alcohol or illicit drug use often includes the
following strategies: (1) identifying intrapersonal and interpersonal triggers for relapse,
(2) coping-skills training, (3) drug-refusal skills training, (4) functional analysis of
substance use, and (5) increasing nonuse-related activities (Magill, 2009).

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Reference
Macdonald G, Higgins JPT, Ramchandani P, Valentine JC, Bronger LP, Klein
P, behavioral interventions for children who have been sexually abused. Campbell
Systematic Reviews:14 DOI: 10.4073/csr.2012.14 .

Magill, M., & Ray, L. A. (2009). Cognitive-behavioral treatment with adult alcohol and
illicit drug users: A meta-analysis of randomized controlled trials. Journal of
Studies on Alcohol and Drugs, 70(4), 516-27. Retrieved from
http://search.proquest.com.proxy.lib.wayne.edu/docview/200447901?
accountid=14925

NCADD-GDA. (2012). We Can HelpMake a Difference in Your Life

Today! [Brochure]. Detroit, Michigan: Author.