Biopsychosocial Assessment Report Paper

I’m working on a Social Science exercise and need support.

Biopsychosocial/mitigation report – “Brian” fact pattern

You are a social worker in his defense attorney’s office (agent of the attorney).

You are asked to write a biopsychosocial/mitigation report to help see if Brian can

get into an alternative to incarceration (drug or mental health court, long term drug

program) or a lesser sentence.

Write a 3-5 page biopsychosocial/mitigation report, incorporating ACES and other

relevant social science information. In your assessment include a possible

program in NY you think Brian could benefit from as an ATI (Alternative to

Incarceration- can be anywhere in NY)

In a separate paragraph explain: What other information would you want to gather

from his life, who else might you want to interview? What do you do with the other

information he disclosed about the crime he is not charged with- what are your

obligations? What are your personal concerns/feelings about this uncharged crime?

and how do you address those concerns?

Please read the fact pattern in its entirety before you start.


Brian was born to his teenage mom (17) and dad (23). Mother received limited pre-

natal care. He was born by C-section, normal range of weight, and released to his

mother. The parents were never married. Brian’s mom never knew her biological

father. Brian did not attend pre-school and had many absences in kindergarten. The

rest of elementary school, Brian was an average student and utilized resource room for

speech and reading. By 6th grade he was on reading level, but not strong with reading


Brian as a 7th grade student (age 12 ½). Brian has lived in the same school district for 4

years, but in three different apartments, this last one for a year. His maternal

grandmother had been very involved until about 3 years ago when his mom had a bad

argument with her and they stopped talking. Brian was told NOT to contact her

anymore, he’s not sure whether she is alive. Brian’s dad was not ever really involved,

having visited with him a few times a year before his current incarceration of 24 years

for drug sales and DWI fatality where he was driving high and killed a mother and child.

Brian has not seen his father in 8 years. Brian lives with his mom, her new boyfriend (5

months dating) and his half-sister, Jenny, who is 7 (from a different relationship). Jenny

sees her father one time a month for a weekend, and some holidays. Brian is very

loving toward his little sister and helps her with homework and watches her when his

mom works late as a waitress, or when his mom and boyfriend go out drinking on the

weekends. Brian has no contact with his father.

Records show that police have been called to the current residence 2 times in the last

month for “domestic incidents”, but none have resulted in any arrests or CPS calls.

Brian has generally been a B/C student. His standardized test scores are all in the

average range. Brian began to experience academic problems in middle school this

year. Although he is very friendly and social, he is currently failing several subjects for

lack of homework, failing tests, and cutting class. The school has scheduled several

conferences, but Brian’s mother cancels last minute, and they have been postponed 3


Recently, Brian had a verbal dispute with a teacher and was sent to the office for

insubordination. While there, Brian was acting strange, seemed lethargic, and had

glassy, red eyes. He was asked to submit to a drug test, which he declined. As per

school policy, his mother was called, and this time did come to the school. After

speaking with her son privately, she asked what the consequences would be if he was

positive for drugs. Upon realizing that he would be referred to PINS, Brian admitted to

smoking marijuana he had found in his home. The school called CPS and filed a PINS.

Mom was investigated by CPS, but the allegations were sparse, no drugs were

found in the home, and the case was “indicated”, but no family court charges were

brought against her. Brian was referred PINS diversion and placed in outpatient

drug treatment, but failed the rest of diversion services partly because his mother

refused to drive him to his appointments for outpatient treatment. He was removed

from his mother at age 14 and was placed in a residential facility under the PINS.

He continued to have trouble at school and in the community. At 16, following a

string of burglaries, it was determined that Brian and another child from the

program had been sneaking out at night and burglarizing homes. Brian had an

unexplained cut on his hand. It was from breaking a back-door window. He left a

blood sample and fingerprints at the house. Upon a search warrant, it was

determined it was Brian’s. Brian was charged with burglary and originally

sentenced to probation as a youth under Raise the Age and placed in a more

restrictive setting. After assaulting a staff person, he was sentenced to a juvenile

detention center, initially for 1 year, which was extended 2 times due to his non-

compliance, lack of effort, and insubordination. Brian’s mother only visited him one

time when he first arrived and failed to participate in any family counseling. Brian

did exchange letters with his sister Jenny monthly, and he gets cards and pictures from her which he valued greatly.

Brian at 20

Following a 3 year stay in a juvenile facility. He is monitored by aftercare

probation. He is living with his mom, having a hard time finding a job, and still

needs his GED. He was diagnosed with Bi-Polar and disclosed he has been using

Xanax (not prescribed). He reports to that the staff he assaulted was trying to

sexually assault him at the program- he states he is not violent otherwise. Brian

states he would like to join the army one day.

Brian barely completed his aftercare. He goes on to commit several

misdemeanors over the next few years resulting in short, local jail sentences three

times. He never completed a long-term treatment program. He works odd jobs

here and there- mostly construction as a day laborer. He did get his GED, but

failed to complete an HVAC program he had been enrolled in through the County.

Brian had been living with his sister for a short time, but her husband kicked him

out when he found drugs in the basement where he was staying. Prior to a recent

arrest, he had been staying in a men’s shelter for recovery- PAX Christie.

Brian at 28

He has been arrested for 3 C violent felonies for alleged home burglaries, he is

currently in custody on $50,000 bail and facing 5-15 years.

Brian has no significant other (and states never has a serious girlfriend) and no

children. He is not currently in any treatment, he is unmedicated- though the jail

will evaluate and may start him on meds, and prior to his arrest was homeless

following a physical altercation with his mom’s newest boyfriend.

You interview him at the jail for the purposes of the biopsychosocial/mitigation

report that has been requested. In addition to all the above information, he admits

to using heroin, Xanax, and anything he can “get my hands on” in the weeks prior

and during these alleged crimes. He also discloses another violent crime where he

injured a person when he robbed them at an ATM (it was in the newspaper), but it

remains “unsolved”.

Below is a sample biopsychosocial assessment. Each individual case is different, but you may use this as a guide to help generate this paper.

Name: ClientAssessment date: 12/11/17

DOB: 6/XX/XXDocket Number: 2016SU00XXXX



Clientis a forty-four (44) year-old Puerto-Rican American (U.S Citizen) male.Client primarily speaks English, but is also fluent in Spanish.Client was born in Brooklyn, NY.He has been incarcerated at the Riverhead SCCF facility for approximately twenty-four (24) months.Client was residing in a private residence in Brentwood (NY) with his long-term girlfriend immediately prior to his current incarceration.Client identifies as Roman Catholic and regularly attends religious services.


Client is currently married to Deborah XXXXX, but has been separated from his wife for roughly over five (5) years.“I was supposed to sign divorce papers and stuff, but then I was arrested.”Client has been dating his long-time girlfriend Wendy XXXX, age forty-three (43), since 2013.Wendy is currently incarcerated at the Riverhead SCCF facility since 9/2017.Client describes his relationship with her as “good,” and that he regularly communicates with her via letter writing.

Client has two biological daughters with his wife Deborah XXXX.His youngest daughter, Theresa xxxxx (age 7), resides with Mrs. XXXXX in Selden, NY.Felix’s oldest daughter, Anna XXXXX (age 22), resides in Nesconset, NY. Client’s children are “doing well.” He shares mutually loving relationships with his daughters and communicates with them when possible via telephone and letter-writing.

Client has mutually loving relationships with both his biological parents.His biological mother, Anna XXXXX (age 56), resides in Florida.His biological father, XXX (age 65), resides in Massachusetts.Client regularly communicates with both parents via letter writing and telephone-calls.

Client is the oldest of five (5) children.Client has one (1) maternal half-b rother (Edwin XXXX), fathered by XXXX’s second step-father (Eddie XXXX), whom resides in Florida.

Client has three (3) paternal half-brothers (Jessie XXX, Michael Rodriguez, and Marvin XXX) whom all reside in Massachusetts.Client has mutually loving relationships and regular communication with all of his siblings.


Client was primarily raised by his biological mother Ms. XXX and various step-fathers throughout his childhood.Ms. XXXX was a teenage mother to Client as she gave birth to him when she was age thirteen (13).Mother and Client’s biological father Mr. XXXX (Sr.) never married, but were together from Client’s birth until age seven (7). “He would still come and go after that.He’s always been there.”Client experienced multiple episodes of parental separation as his mother had several different long-term romantic partners at separate points in Client’s childhood.“Children from divorced families have more behavior problems, more social difficulties, more psychological stress and poorer academic performance (Clarke-Stewart, Vandall, McCartney, Owen & Booth, 2000).”

Client and his mother moved to California when he was approximately seven (7) years-old to live with his first step-father, Chris XXXX, until Client was age eleven (11).Mr. XXXX severely and chronically physically abused Client and his mother throughout the duration of their time residing together (see Trauma History).

Client and his mother began living with his second step-father, Eddie XXXX, when Client was approximately age thirteen (13) until age eighteen (18).Client and his mother largely resided in Brentwood (NY) from when Client was approximately age thirteen (13) to adulthood.Mr. XXX and Client’s mother were mutually assaultive towards one another throughout their relationship together.Client consequently engaged in physical altercations with Mr. XXXX in order to protect his mother multiple times.Client’s behavioral and substance abuse issues worsened following Mr. XXXX’s departure from the home.Client remained “friends” with his step-father after his mother leaving Mr. XXXX.Client’s and Mr. XXXX’s mutual substance abuse escalated at this time, which included Mr. XXXX introducing Client to heroin (see Substance Abuse History).Despite this toxic and dysfunctional relationship of mutual violence and substance abuse, Client is under the belief that he has largely held a healthy and functional relationship with Mr. XXXX.


Client graduated from Brentwood High School in 1993.Client experienced pervasive behavioral problems throughout grade school that stemmed from his ongoing physical abuse received at home, substance abuse issues, and the emotional turmoil caused by his multiple relocations as a child. “It was rough always being the new kid.I always had problems with truancy and getting high.”Client also attempted to conceal the abuse inflicted by Mr. XXXX from his mother and school officials, leaving Client feeling emotionally isolated.

Client attended barber vocational schooling while living and working in Florida from approximately 2006 to 2008.Client was unable to complete this course and attain his barber license after relapsing with substances and losing his employment (see Substance Abuse History).


Client currently works in the Riverhead SCCF barber shop. “I love cutting hair.”Client has been working “on and off” as a barber since approximately age sixteen (16).When not employed as a barber, Client has held odd-jobs, such as in construction and customer service call centers.


Client required emergency surgery in 2002 due to a neck laceration sustained during a fight.

Client was briefly hospitalized in 1998 due to overdose symptoms when he attempted to independently detox from heroin from his home.Client had consumed sleeping pills and smoked marijuana in order to mitigate the severity of his heroin withdrawal symptoms.“I had a bad reaction from combining them.I was hallucinating and stuff.”Client required having his stomach pumped in the responding ambulance before being transported to Southside Hospital.


Client was severely physically abused on a regular basis while he and his mother resided with Mr. XXXX.“He would beat me until I pissed myself.He’d wait until my mom left.I never said anything about it to her until I was an adult.He hit her too.”

“Prospective research has shown that individuals abused and neglected as children were approximately 1.5 times more likely to report illicit drug use in the past year compared to healthy, non-abused, non-neglected controls (Spatz Widom, Marmorstein, & White, 2006).

Client shared that Mr. XXXX once had repeatedly submerged Client’s head underwater in the bathroom sink until Client would nearly lose consciousness.Mr. XXX would momentarily release Client for air before going on to repeat this process. Client and Ms. XXX one day waited for Mr. XXXX to leave for work before moving out of the home, and returning to Brooklyn, out of fear for their safety.

Mr. XXXX was once incarcerated at the same correctional facility as Client.“You could tell he was nervous when he saw me.He knew what he did. I wasn’t a kid anymore.He was transferred or released a little later. I don’t remember which.”

Client denies ever being the recipient of sexual abuse or molestation.

Client has coped with PTSD-like symptoms since childhood, especially when in the presence of violence or confrontation.These symptoms include shakiness, anxiety, hoarseness, flashbacks to instances of abuse, nightmares of violence, and hypervigilance.“It reminds me of when I would be in my room and listening to my parents fighting, waiting to hear if my step-dad was going to hit my mom or not.”Client reports that these feelings can even be triggered by depictions of violence on television. “Witnessing domestic violence can have serious adverse effects on children’s well-being, including psychological, emotional and behavioral problems. This can include aggressive, antisocial behaviors and PTSD symptoms (Meltzer, Doos, Vostanis, Ford, & Goodman, 2009).”


Client has experienced feelings of depression and anxiety since childhood.He has never engaged in any capacity of mental health treatment until his most recent incarceration, as he has been engaged with the Riverhead SCCF psychiatrist.Client could not recall this doctor’s name.Client has been prescribed Elavil (antidepressant) since his incarceration to assist with insomnia and depression.Client is being prescribed an additional medication, but he could not recall its name.

Client denies any h/o suicidal ideations or suicide attempts.


Client began using heroin with his second step-father at approximately age twenty-one (21).He last used heroin (intranasal) approximately two (2) years ago.Client was using upwards of approximately two (2) bundles of heroin a day while actively using.

Client began using marijuana at age twelve (12).Client last used marijuana approximately two (2) years ago.Client was smoking upwards of one (1) to two (2) “blunts” a day while actively using.

Client began using acid ate age seventeen (17).Client used acid “a couple times a year” when younger and would “go to school tripping out.”Client last used acid in 2002.

Client began using cocaine at age seventeen (17). Client used cocaine approximately once per month and consumed an average of one (1) gram of cocaine while actively using.Client last used cocaine approximately two (2) years ago.

Client began drinking alcohol at age fifteen (15).Client would drink approximately three (3) to four (4) days per week and would consume approximately a six (6) pack of beer in a sitting while actively using.Client last drank approximately two (2) years ago.

Client has maintained extended periods of sobriety while engaged in substance abuse treatment programs.Client has also remained sober when incarcerated.

Client entered into detox programs for heroin withdrawals at Southside Hospital (Bayshore, NY) in 1997 and Woodhall Medical Center (Brooklyn, NY) in 2002.Client has also attempted to detox from heroin independently from home multiple times.

Client engaged in long-term inpatient at Phoenix House (Ronkonkoma, NY) in 2003 and completed in 2004.Client then transferred to Seafield Center non-intensive outpatient treatment program in 2005 and completed in 2006.Client also resided in Seafield Center sober housing during this time frame for approximately three (3) to four (4) months, before moving to a private residence once his housing benefits expired.Client attended and completed the CK Post long-term inpatient treatment program in 2008.Client again engaged in long-term inpatient treatment at Phoenix House in approximately in 2010 to 2011 before successfully completing this program. Lastly, Client engaged in outpatient treatment at C.A.R.E (Bohemia, NY) in 2012.

Client has attended NA meetings “on and off” since 1997.“I had a sponsor one time.”He has also been attending NA meetings while incarcerated at Riverhead SCCF.

Client was prescribed Suboxone in 2009 for several months from “a program in Mastic.”Client could not recall the name of the prescribing agency.“It was working for me.I couldn’t afford it after a while, though.”Client had been receiving Vivitrol injections for approximately two (2) years while incarcerated at Riverhead SCCF until recently.“They had to take me off of it because I’m going upstate.”


Client regularly attends religious services.He stays in regular contact with his girlfriend and family via telephone calls, visits, and letters.Client attends NA meetings.He mainly preoccupies his down time by reading, exercising, and working.


Client is a family-oriented person, and is greatly motivated by his love for his family to maintain a sober lifestyle so that he may lead a fulfilling life and be a functioning member of society.

Client has struggled with substance abuse throughout his life; and yet, he has still shown the ability to independently seek out and complete treatment following relapses.Despite his life-long struggle with sobriety, Client has continually (and voluntarily) engaged in multiple substance abuse treatment programs. Client had also found relative success while receiving Suboxone therapy, but was forced to discontinue this treatment due to his inability to afford his copayments.

Client’s substance abuse issues appear connected to his childhood history, particularly in regards to his mother’s revolving-door policy for physically and emotionally abusive toxic male role models.The prevalence of violence in Client’s upbringing had a profound effect on his development, as Client lashed out in childhood delinquent behaviors, as well as seeking emotional solace in substances. Following the separation of Client’s biological parents, every father-figure in Client’s life has either severely physically abused him and/or introduced Client to substances – including heroin.According to Gill (2014), “shaky or poor sense of self/self-esteem and interpersonal relationships leave addictively prone individuals subject to discover the ameliorating effects of addictive substances and behaviors. Feelings of poor self-cohesion and fragmentation are relieved by the calming action of opiates or sedatives in such individuals.”

Client experiences PTSD-like symptoms as a consequence of his history of abuse.Client became visibly anxious when speaking of his history of abuse and his symptomatic reactions to violence; such as continuously shaking his legs, an inability to make eye contact with this worker, wringing his hands, and exhibiting an overall appearance of restlessness.

Client feels tremendous remorse for his illegal behavior and for those he has wronged by both his criminal behavior and substance abuse.He expressed a strong desire to attain a truly sober lifestyle where he is a productive member of society and is present in his children’s lives.He is strongly recommended to maintain a life-long presence in substance abuse treatment and to explore reengaging in Vivitrol/Suboxone therapy once he is able to do so again.It is also strongly recommended that Client engage in mental health counseling to assist in processing his life-long experiences of physical abuse, anxiety, and depression.


Cognitive (memory, intelligence): Adequate historian, Average intelligence
Attitude toward social worker: Cooperative, amicable
Behavior: Anxious
Thoughts Process/Speech:Fluid
Judgment/ Insight: Average
Mood/Affect: Euthymic/appropriate
Perceptual Disturbances: Denied presence of hallucinations or delusions

Completed By:


Harrison Grimm, LMSW

Works Cited

Clarke-Stewart, A., Vandell, D., McCartney, K., Owen, M. (2000). Effects of parental separation and divorce on very young children. Journal of Family Psychology, 14, (2), 304-326.DOI: 10.1037//0893-3200.12.2.304

Gill, R. (2014). Addictions from an attachment perspective: do broken bonds and early traumalead to addictive behaviours? London, England: Karnac Books Ltd.

Meltzer, H., Doos, L., Vostanis, P., Ford, T., & Goodman, R. (2009). The mental health ofchildren who witness domestic violence. Child and Family Social work, 14, 491-501.DOI: 10.1111/j.1365-2206.2009.00633.x

Spatz Widom, C., Marmorstein, N. R., & Raskin White, H. (2006). Childhood victimization andillicit drug use in middle adulthood. Psychology of Addictive Behaviors, 20, 394–403.doi:10.1037/0893-164X.20.4. 394

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