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Running head: BIO-PSYCH-SOCIAL ASSESSMENT

BIO-PSYCH-SOCIAL ASSESSMENT
Tracy Hawthorne
EK1877
SW 3020
Wayne State University
July 31, 2015

BIO-PSYCHO-SOCIAL
Demographic Information
Name: Keith Martin

Date of Birth: 08/13/1972

Address: 101 E. Grand Blvd

Age: 42

Telephone Number: 586-555-0000

Sex: Male

E-mail: kmartin@gmail.com

Ethnicity: African American

Intake Clinician: Tracy Hawthorne

Date of Interview: 07/30/2015

Presenting Problem
Keith Martin is a forty-two-year-old single African American heterosexual male alcoholic who
lives alone in a three-bedroom home in East Detroit, MI. He has been an employee of the
Chrysler Motor Company for eighteen years. Keith is at risk of losing his job because of his
work performance and poor attendance due to more-than-necessary alcohol use. Keith was
referred for counseling assessment as a result.
Family of Origin History
Keith is the youngest of three children. He has two older brothers. His brothers are Terrance
Martin, age forty-three, and Clinton Martin, age forty-four. Terrance and Clinton both are
married and have children. Terrance has one twenty-year-old daughter named Star Martin, and
Clinton has an eighteen-year-old daughter named Ashley Martin. Keith's parents, Kay and Bob
Martin, have a highest level of education of 12th grade. They were twenty- years old and had
been married for eleven months when Keith was born. Keith's mother worked for a local market
from age twenty until she retired at sixty-eight years old. Keith's father worked for General
Motor Company from age twenty-five until he passed away at sixty-four-years-old

BIO-PSYCHO-SOCIAL

due to heavy alcohol use; he developed cirrhosis of the liver. Keith's older sibling Clinton, at
fourteen years old, babysat he and Terrance while their parents were at work. Keith parents did
not fight, and the house was quiet while he was growing up. The father's alcoholism abuse was
not discussed. His mother and siblings love drinking but only did it socially. All members of the
Martin family are presently in good health and denied any illnesses.
Developmental History
Keith was born full term at thirty-seven weeks through vaginal delivery. He weighed five pounds
and six ounces. His mom had no health issues during pregnancy or delivery. Keith was breastfed
until age ten months. There were no developmental delays. He began walking at ten months and
was potty trained at sixteen months.
Health History
Keith was born healthy. He denied any illness, broken bones, surgeries, or weight issues. Keith is
five feet nine inches tall. He weighs two hundred fifty pounds. At age three, Keith had the
chicken pox that cleared up completely in twelve days. He does not currently take any
medications.
Relationship/Sexual History
Keith has two close friends from childhood and one friend he met at the bowling alley where he
bowls. He has had eighteen sexual partners, all women. Keith began dating at sixteen years old,
which is also when he became sexually active. His first dates were High school girls that he had
known since middle school. Keith reports he has been in six relationships, and his last
relationship lasted twelve years. That was the longest relationship of the six. Keith has used
condoms during every sexual encounter up until the past 12 years of his previous relationship.

BIO-PSYCHO-SOCIAL

He has never had a sexually transmitted infection or disease. Keith's last relationship ended three
and half months ago because of his failure to seek treatment for his alcohol abuse.
Family of Creation History
Keith has never been married and had one son Keith Jr. (pseudonym) born in the year 2009, who
was killed at the age of seven by a hit-and-run driver eight months ago. This incident is when his
increase of alcohol abuse started. The birth of his son was not planned and when the discover of
the pregnancy was found out abortion and/or adoption was not considered.
Substance Use/Abuse History
Keith has been drinking since he was fourteen years old. His alcohol of choice is Bacardi, but he
does not care what brand as long he can get a drink. He has approximately one fifth bottles or
more a day. Keith starts with pouring a couple of shots in his coffee every morning before work.
He also keeps an extra-large coffee mug filled with alcohol and coffee to drink throughout the
workday, while working as a tradesman. He drinks and drives. He has never felt it was a problem
until now, which is why he sought treatment for his alcohol use.
Mental Health History
Keith denied mental health issues.
Military History
Keith denied military service.
Financial History
Keith grew up in a middle-class neighborhood and household. Both parents worked, so Keith and
his siblings always were provided with everything they needed and never wanted for anything.
Keith currently grosses about forty-five thousand per year and lives within his means. He has a

BIO-PSYCHO-SOCIAL
checking account with about twenty thousand dollars in it. He also has forty-one thousand
dollars in his 401K and owns three thousand dollars' worth of stock with Chrysler Motors.
Legal History
At age twenty-one and thirty, Keith was arrested in 1994 and 2003 for drunk driving. However,
Keith did not receive a DUI and was not incarcerated for his irresponsible actions. In 2015,

twelve years later, Keith's license was suspended with restriction giving him permission to drive
to work only and counseling being the court is aware he already seek counseling.
Immigration Issues
Keith denied issues related to immigration.
Step 1: Working with The Client
Mr. Martin has established several problems he wishes to address. His priorities include issues:
1.

Finding stability to be a functioning member of society, without the use of alcohol.

2.

Seek help from a professional therapist.

3.

Deal with a death of his son.


Step Two: Prioritize the Problems

1.

Missing work and poor job performance

2. Aggressive drinking behavior


3.

Grief
Step 3: Translate Problem into Need

1. The need to learn how to surrender alcohol.


2. The need to find assistance to solve this self-abuse.
3. The need to faced his child death without the influence of alcohol.

BIO-PSYCHO-SOCIAL

Step 4: Evaluate Levels of Intervention for Each Need


Need:#1 Manage was not having any mind moving chemicals
Micro Strategy: Individual counseling to identify he is an addict.
Pros: To have acceptance will allow Mr. Martin to realize never in life can he use any drugs.
Needs: This could give the client a new way of life.
Cons: Mr. Martin need to understand his addiction is a disease that is cunning and baffling. Also,
his disease is made of obsessive and compulsive.
Mezzo Strategy: Group session to learn the therapeutic value of one addict helping another.
Pros: Listening to other people share their story, realize you are not alone.
Cons: Knowledge of a relapse.
Macro Strategy: Treatment Center with psychiatric therapy
Pros: Dealing with the broader community
Cons: Keeping structure.
Need:#2 Finding help with assisted for Mr. Martin
Micro Strategy: Scheduling regular family members counseling.
Pros: One day at a time living an ordinary life
Cons: If Mr. Martin do not accept hope that he never has to drink again.
Needs: This could give the client a new way of life.
Cons: Mr. Martin need to understand his addiction is a disease that is cunning and baffling. Also,
his disease is made of obsessive and compulsive.
Mezzo Strategy: Group session to learn the therapeutic value of one addict helping another.
Pros: Listening to other people share their story, realize you are not alone.

BIO-PSYCHO-SOCIAL
Cons: Knowledge of a relapse.
Macro Strategy: Treatment Center with psychiatric therapy
Pros: Dealing with the broader community
Cons: Keeping structure.
Needs #3 Dealing with his child death.
Micro strategy: Accepting his son death.
Pros: Reduce stress
Cons: Not able to accept the death of his son
Mezzo level: Traumatic events
Pros: Dealing with psychological impact
Cons: Feelings of guilt
Marco strategy: Dont apply
Treatment Plan
I.
A.

Keith will learn the skills needed to live a clean and sober life.
Keith will report to Share House Treatment Center as an outpatient, by 26 July 2015 to learn

coping skills.
1.

By August 1st, 2015, Keith will meet with a Share House therapist twice a week for twelve

months.
2.

Starting no later than August 7th, 2015, Keith will be introduced to the Alcoholics

Anonymous program.
B.

Keith will make 90 meetings in 90 days, or a meeting a day.

BIO-PSYCHO-SOCIAL
1.

Keith would purchase at the meeting a Basic Text Alcohol Anonymous book by 7th of

August 2015.
2.

Keith would read the first chapter in the book by 7th of August, 2015, focusing on Step One:

"We admitted that we were powerless over our addiction, that our lives had become
unmanageable".
II.

Keith would learn skills of writing in a journal, explaining how step one applies to his life.

A.

Keith will seek a sponsor, a person who has knowledge of the twelve step program.

1.

Keith will learn to identify high-risk situations or stressors, called triggers, to keep him from

relapsing to his drug of choice.


2.

Keith will learn to sit down at an NA or AA meeting table and share his experiment with

alcohol.
B.

Keith will learn to understand how alcohol abuse affects everyone in his life.

1.

Keith will apply Step 8: "We made a list of all persons we had harmed, and became willing

to make amends to them all" within the next week.


2.

Keith will allow family and friends to express how his drinking affected their lives. After

this step, Keith will be able to live a clean and sober life, taking it one day at a time.
Contract for Intervention Plan
Client Name: Keith Martin (Pseudonym)
Description of Problem:
Mr. Martin is in need of treatment and understanding alcohol abuse is an illness. He is referral to
a treatment facility to understand his daily triggers and stresses that lead to alcohol use in the
first place. Also, Keith needs to realize this help conceptualize the process of recognizing there is

BIO-PSYCHO-SOCIAL

a drinking problem and taking control of the situation. Recovery will be an ongoing life event,
like a social worker when Keith is released from my care, he will need a sponsor for there are
some event Keith may have experiment that are so personal he may feel uncomfortable talking
about them at a meeting. Keith will address his feeling about the death of his sons. Through these
treatments he will be able to live a clean and sober lifestyle.
Primary Goals:
1.

Enhance the clients motivation for change.

2. Teaching the client to break an addiction by learning to establish total meaning of being
abstinence from all mood-altering drugs.
3. Teaching the client coping and problem-solving skills.
4.

Support and guide the clients giving them the knowledge to prevent relapse.

We, the undersigned, agree to the objectives in the following plan:


A. The client will go to see a therapist.
B. The client will work on coping skills.
C. The client will be introducing to Alcoholics Anonymous Program.
D. The client will learn therapeutic value in writing.
E. The client will grieve the loss of his son.
F. The client will seek a sponsor.
G. The client will allow family and friends to express their selves.

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BIO-PSYCHO-SOCIAL

Bibliography
(pseudonym) Martin, K. (2015, July 14). Keith Martin Background. (T.Hawthorne, Interviewer)
Step One Home - Steps Foundation. (n.d.). Retrieved from
http://www.stepsfoundation.com/Step1P1.htm
Step Eight "Made a list of all persons we had harmed, and ... (n.d.). Retrieved from
http://friendofdrbob.com/stepstradition/8Step.htm

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