Biopsychosocial Assessment Pseudo Client

Name: Ronald
Date of Birth: n/a
Date of Assessment: 4/1/20

PRESENTING PROBLEM
Ronald is a muscular, and straightforward 50 year old Caucasian male. Mother and father is
unknown at the time of this assessment. Ronald was first referred by his wife, Mary, to start
coming to counseling. Ronald was referred because of an increase in arguments in the household
and that Ronald is ‘angry all the time’. After discussing with Ronald a little more about his
relationship with his wife and possible recent challenges, it seems that Ronald has a challenge
with controlling his anger. Ronald describes that his arguments with his wife escalates to
shouting as well as shoving her when he becomes angry. He is worried about harming her, if in
an argument, his anger becomes too intense that he physically harms his wife.

HOUSEHOLD DESCRIPTION
Ronald currently lives with his wife, Mary age unknown. They do not have any children and they
are the only two who live in the space and they have been together for 15 years. Mary currently
does not have a job. Ronald works as a laborer and does construction work. He has worked in
this field for 20 years. Ronald is the only one who has an income and he is the main supporter of
the family. There living situation has not changed however, there has been a change in Ronald’s
work. In recent events Ronald is currently not working because of the lack of need for
construction work due to the season. Ronald is currently unemployed and is waiting for work to
‘pick up’ again. They both live together at 131 Summer Street.

HISTORICAL AND DEVELPMENTAL DATA

Ronald has not shared a lot of information about his childhood or his parents. What is currently
known is that he grew up in the foster care system and when asked about his biological parents
says that he has no relationship with them. He mentioned that he was in a boy’s home until he
aged out at 18 years old. He claimed to not have any siblings and does not know anything about
his biological family.
The lack of a family support network seems to affect Ronald in a way where he has had
to become his own support. When asking about his support network he did mention his
coworkers however, when asked about whether or not he asks them for help or support he denied
it. He says that everyone comes to him for help but he does not seek out help from others.
Ronald also has trouble with controlling his anger and has mentioned that he has gotten into a
few bar fights when he was younger. He did claim that he does not get involved in them now.
In the intake form Ronald has mentioned that he is catholic however, that is not a topic
that has come up during our sessions and so there is a lack of information regarding his religious
practice and belief.
The last educational level that Ronald finished is second year of high school. Ronald
seems to have had a few close friends and seems to not expand his friend group. In the present
his closest friends are his coworkers and he has mentioned that they are like brothers to him. He
does not mention having friends outside of his coworkers. Ronald has also never served in the
military after leaving school.
Ronald seems to have taken odd jobs after leaving high school and landed in construction
where he found his passion. He mentions that he likes to fix objects and feel useful. He is
currently still working in a construction company and has been working there for 20 years.
Ronald is currently married to Mary and they have been married for 15 years. They do
not have any children together and they live together. Their relationship seems to be
experiencing some challenges after Ronald has not been working. There have been frequent
arguments between the two and seems to be escalating as time goes by. By Ronald’s account,
Mary is frequently asking him questions or ‘starting arguments’ with him and once the argument
escalates Ronald describes that he is made out to be the ‘bad guy.’ This is stemming from the
anger that he exhibits when their arguments escalates.
The friends that Ronald has are his coworkers who he describes as being like his brothers.
They meet together to drink at a bar and talk about their works. When asked if he seeks help
from his friends, he mentions that he does not and generally talks to his wife if need be. From
Ronald’s description, he seems to be the main person that people come to with problems and he
feels the need to help them. It seems that they have not been meeting as often since his
coworkers have found other jobs and are busy more often than when they worked together.
Ronald does not seem to be a part of any organizational whether it be educational, social
professional, or cultural. Though it is unknown whether Ronald partakes in any religious
organizations. Ronald mentioned having some persona activities that he enjoys. He enjoys to
break and fix objects that are around the house; and he has mentioned that he enjoys running.
However, in recent months he has not been partaking in activities that he enjoys.
Ronald does not have any preexisting health problems and is in generally good shape.
This is his first time in therapy and he has never been hospitalized prior to meeting. He has
denied any challenges with drugs or alcohol. He has mentioned that he does indulge in drinking
beer. He drinks between 2-3 bottles each time that he does drink. Now that he is out of work, he
has claimed that he drinks every day.

CLIENT CONTACT
Ronald has been seen 1 weekly for three individual sessions. Ronald has slowly begun to open
up about his worries with his wife and has started to see the sessions as his time and space that he
is able to utilize to his liking. When starting counseling he had repeatedly mentioned how he
should not be in therapy and that if there is a problem it should be dealt with within the home. He
seemed to be very reluctant to be in therapy but still had motivation to come. He stated that he is
willing to try therapy for his wife who is the one who had referred him. As time has progressed,
he has opened up more and whenever asked questions during a session, he will answer to as
much as he is comfortable. He has shared his personal goal that he would like achieve which is
for him to be able to control his anger.
Other current goals for Ronald is for him to be able to find healthy coping techniques for
when he is starting to feel anger surging from an argument. He has been practicing one technique
which we have spoken about which is taking a walk since he had mentioned enjoying walks with
his wife before. The current goal is to be able to build on more techniques as to lessen the anger
that may be produced from the arguments. Ronald still seems to not take responsibility for his
anger when in the argument and blames his wife for constantly pushing him. Another goal that I
am hoping to have for Ronald is being able not only have more insight but being able to see
other’s perspectives such as his wife’s. Another goal is to expand the support network that he
currently has that consists only of his wife and his coworkers. Through conversations it seems
that he is not finding the support that he needs through his coworkers and so to be able to have a
group that he is able to interact with people who are not just from his work or his wife I would
think would be beneficial for his well-being. Along with finding healthier techniques to cope
with his anger, being able to get back into activities and social events might help in reducing the
frequency of his frustrations with his wife. He has mentioned that he is home a lot because of the
lack of work and so is his wife.
Ronald only recently is able to talk and elaborate more about what is has been
manifesting within his household with he and his wife. There are still areas that are unknown that
may be causing Ronald a difficult time in adjusting from his lack of work so the prognosis as this
time is unknown and can only be approximated as fair.

Prepared by Mayuko Yamamoto