Family Assessment and Psychotherapeutic Approaches Essay

Family Assessment and Psychotherapeutic Approaches Essay

Family Assessment and Psychotherapeutic Approaches Essay

Week (#): Family Assessment and Psychotherapeutic Approaches

eNRNP/PRAC 6645 Comprehensive Psychiatric Evaluation NoteThe Psychiatric/ Mental health nurse performs complex functions in care delivery. They assess families and individuals comprehensively to determine areas of need, their physical and cognitive health, and their family cohesiveness. They work with the interprofessional team to fulfill these needs. Assessing families is somewhat complex and differs from individual analysis because the focus is to manage the family trauma and rewire the dysfunctional patterns in the family. This comprehensive psychiatric evaluation note focuses on Patti’s family and a dysfunctional pattern blamed on the arrival of her daughter, who had been left behind in Iran and recently rejoined the family.

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CC: (chief complaint): “Chaos in Patti’s family since her daughter rejoined the family.”
HPI: A mother (Patti), her daughter, and the family therapists came to the healthcare facility complaining of chaos in the family since her daughter Shireen came to the US. The family immigrated from Iran 12 years ago, and a 10-year-old daughter was left behind before processing her visa and joining the family in the United States. Chaos (blaming, arguing, cursing) arose when she rejoined the family and told them of the trauma and abandonment she went through after she was left behind during the immigration. Patti complains that her children are out of control, and she no longer feels in charge. The family therapist states that Shireen, the 21-year-old, claims she needs more money than a therapist and refuses to attend all appointments. Shireen has been through trauma after being sexually and physically abused by her father when the mother chose to stay with the four kids in the US and not return to Iran. Patti is also attached to her culture; the daughters try to detach from their mother and live independently. Patti has had two foot surgeries, creating more family tension. Patti often feels hopeless, helpless, and detached from the children and has been advised to get psychiatric help. Patti admits to needing help to learn to detach from the kids and live independently because of her cultural affiliations.
Past Psychiatric History:
• General Statement: The client has a history of fights and disagreements in the family due to cultural problems and started family therapy about two years ago
• Caregivers (if applicable): Not applicable
• Hospitalizations: 2 years ago, after two-foot surgeries
• Medication trials: None
• Psychotherapy or Previous Psychiatric Diagnosis: None
Substance Current Use and History: Denies current and past substance use history.
Family Psychiatric/Substance Use History: History of domestic trauma (battery), child sexual, immigration trauma of leaving a child behind, fairly traumatic current illness for the mother
Psychosocial History: The client and her children were born in Iran and migrated to the US 12 years ago, leaving a daughter behind who rejoined them later. She has five children; the oldest daughter is a 24-year-old daughter, a 21-year-old daughter, an 18-year-old son who is a student, and a 15-year-old son. The 21-year-old got married recently. The oldest daughter works in promotional jobs and working on getting her real-estate job license. The father, back in Iran, remarried and did not admit her mistakes of abusing Shireen. Patti worked at caregiving and has not been involved in any current or past legal issues. After bringing her child for medical attention in the US, Patti decided to stay and ran away from her husband, who used to beat and abuse her as she protected the children. At home, she quarrels with the children, argues, and curses over issues such as the need for assistance, controlling the children’s lives and dogs, and spending personal time, and she admits that there is a need for change.
Medical History:
• Current Medications: None
• Allergies: No known drug or food allergies
• Reproductive Hx: She has four children. LMP three weeks ago, no pregnant or lactating, heterosexual.
ROS:
• GENERAL: The patient denies any recent weight gain, fatigue, weakness, fever, chills, or night sweats
• HEENT: Denies headaches or recent traumas. Eyes: Denies pain, itchiness, dryness, or drainage. Ears: Denies ear pain, drainage, ringing, loss of balance, or hearing changes. Nose: Denies any pain, drainage, or congestion. Throat: Denies pain swallowing, dryness, itchiness, or sputum production
• SKIN: Denies rashes, itchiness, swelling
• CARDIOVASCULAR: Denies palpitations, high blood pressure, or chest pain
• RESPIRATORY: Denies cough, wheezing, crackles, congestion, or shortness of breath
• GASTROINTESTINAL: Denies changes in appetite, constipation, diarrhea, or abdominal pain
• GENITOURINARY: Denies pain micturition, color or odor in urine, increased urgency or frequency
• NEUROLOGICAL: Denies headaches, syncope, or loss of coordination
• MUSCULOSKELETAL: Reports having had two previous leg surgeries, has excruciating pain hence movement problems
• HEMATOLOGIC: Denies easy bruising, uncontrollable bleeding,
• LYMPHATICS: Denies lymphadenopathy
• ENDOCRINOLOGIC: Denies cold or heat intolerance or excessive sweating
Physical exam: Not Applicable. Performing a physical exam may help determine any physical needs that would inform care delivery.
Diagnostic results: No diagnostic tests were ordered
Assessment:
Mental Status Examination: Patti is a 40-year-old lady who appears the stated age. She is cooperative throughout the encounter. She has dressed appropriately and portrays no tics or other abnormal facial movements. In addition, her speech is coherent, clear, and in appreciable volume and tone. The thought process has no tangentiality, circumstantiality, thought block, or flight of ideas. She reported her mood as happy and displayed a broad congruent affect throughout the encounter. She denies any tactile, auditory, or visual hallucinations or illusions. She does not display delusional thinking or suicidal or homicidal ideations. She is alert and well-oriented to time, place, person, and occasion. Her immediate recall and ratio, recent, and remote memories are intact. In addition, she has good insight and judgment. She denies sleep or appetite changes.
Differential Diagnoses:
Adjustment Disorder with Depressed Mood
According to DSM-5, adjustment disorder is diagnosed when emotional and behavioral symptoms are in response to an identifiable stressor, occurring within three months of the stress onset (APA, 2022). The patient is often tearful, hopeless, and helpless and even exhibits bizarre behavior, such as demanding kids to spend time with her. This family has been experiencing disturbances since the daughter came from Iran. O’Donnell et al. (2019) note that behaviors such as aggression, demanding character, hopelessness, helplessness, cursing, and shouting are clinical manifestations of the adjustment disorder. The family is trying to adjust to the new realities, especially when trying to understand their sister and all the trouble she went through in Iran. Patti is also trying to cope with stressful changes, from an inability to work after two surgeries affecting her walking ability. She also needs adjustment to the new reality that she cannot entirely rely on the children for all her needs or be controlling or too demanding because they are already grown-ups. Thus, this is the primary diagnosis for this patient.
Dependent Personality Disorder
The condition presents with an excessive need to be cared for by others. It involves submissiveness and a need for constant reassurance, and the inability to make decisions (Heintz et al., 2021). The DSM 5 states that a person with this disorder displays a fearful and anxious presentation, excessive need, and dependence on others (APA, 2022). Patti has dependent behavior, but hers is more controlling than fearful. She demands that her children spend all day with her. However, she admits that she is unhappy they are arguing and fighting with her children because she loves them. She does not display a submissive and fearful character, thus ruling out the diagnosis.
Acute Stress Reaction
Acute stress disorder is caused by exposure to traumatic events that involve death, serious injury, sexual violence, and other symptoms, which must begin within three days of the event but last more than three days but subside within a month (APA, 2022). It must cause distress or impairment. Shahrour and Dardas (2020) note that acute stress can cause significant distress and occurs when individuals feel out of control. The daughter’s arrival, the stories she gave the family, and the blaming and the illness could have caused acute stress to the mother. She also presents as being depressive, hopeless, and helpless at times. However, these symptoms have persisted for more than a month, ruling out the diagnoses.
Case Formulation and Treatment Plan: Initiating Patti’s individual psychotherapy and family therapy every two weeks to help the client live a more independent life away from her children and to ensure her children support her as she learns to live independently. Hoffman and Stein (2022) note that psychotherapy is an effective treatment for adjustment disorders as it helps patients deal with the patterns responsible for them. The recommendations were discussed with the family therapists, who agreed with the treatment plan and promised to cooperate. The family also consents to the arrangement for better family outcomes for this troublesome family. Returning to the clinic in four weeks will help the healthcare providers assess change and make other management decisions for better health outcomes.
Reflections
Working with this family and therapist was a complex activity that I could have improved in many ways. I agree with the preceptor’s diagnosis because Patti presents with a need for psychiatric interventions, as seen in her portrayal of maladjustment behaviors. In the future, I will ensure I listen to the family keenly before trying to start conversations. I will also establish some background rules to prevent patients from fighting or disagreeing harshly in the room, which can impede care delivery. The care provider must ensure a therapeutic environment for effective problem management (Wheeler, 2020). Culture is essential to any individual, and these children also need to understand their mother and be supportive as she adjusts to the new realities. Thus, their involvement in family therapy is crucial. Educating the patient on identifying other sources of social support, such as community and religious groups, would also help relieve the overreliance on her children.

References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787
Heintz, H. L., Freedberg, A. L., & Harper, D. G. (2021). Dependent personality in depressed older adults: a case report and systematic review. Journal of Geriatric Psychiatry and Neurology, 34(5), 445-453. https://doi.org/10.1177/0891988720933361
Hoffman, J., & Stein, D. J. (2022). What are the pharmacotherapeutic options for an adjustment disorder? Expert Opinion on Pharmacotherapy, 23(6), 643-646. https://doi.org/10.1080/14656566.2022.2033209
O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International journal of Environmental Research And Public Health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537
Shahrour, G., & Dardas, L. A. (2020). Acute stress disorder, coping self‐efficacy and subsequent psychological distress among nurses amid COVID‐19. Journal of Nursing Management, 28(7), 1686–1695. https://doi.org/10.1111/jonm.13124
Wheeler, K. (Ed.). (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing.

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FAMILY ASSESSMENT
Assessment is as essential to family therapy as it is to individual therapy. Although families often present with one person identified as the “problem,” the assessment process will help you better understand family roles and determine whether the identified problem client is in fact the root of the family’s issues.

REQUIRED TEXTS:
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787

Note: This required text is available for purchase. It is also accessible through the Walden Library.
Nichols, M., & Davis, S. D. (2020). The essentials of family therapy (7th ed.). Pearson.
Wheeler, K. (Ed.). (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing.

THE ASSIGNMENT
Document the following for the family in the video, using the Comprehensive Evaluation Note Template:
• Chief complaint
• History of present illness
• Past psychiatric history
• Substance use history
• Family psychiatric/substance use history
• Psychosocial history/Developmental history
• Medical history
• Review of systems (ROS)
• Physical assessment (if applicable)
• Mental status exam
• Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5-TR diagnostic criteria
• Case formulation and treatment plan
• Include a psychotherapy genogram for the family
Note: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning.

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Criteria Ratings Pts
Document the following for the family in the
video, using the Comprehensive Evaluation Note Template: • Chief complaint• History of present illness• Past psychiatric history•
Substance use history• Family
psychiatric/substance use history• Psychosocial
history/Developmental history• Medical history• Review of systems (ROS) • Physical assessment (if
applicable) 20 to >17.0 pts
Excellent 90%–
100%
The assignment includes an accurate, clear, and complete
description of the subjective and objective
information for the client family. The response addresses each of the required
elements and demonstrates thoughtful
consideration of the client family’s situation and
culture. 17 to >15.0 pts
Good 80%–89%
The assignment includes an accurate, clear, and complete description of the subjective and objective
information for the client family. 15 to >13.0 pts
Fair 70%–79%
The assignment includes a
description of the subjective and objective
information for the client family but is somewhat general or contains small
inaccuracies. 13 to >0 pts
Poor 0%–69%
The
assignment includes a
description of the subjective and objective information for the client
family but is vague or contains many inaccuracies. Or, several of the required
elements are missing.

20 pts
• Mental status exam • Differential diagnoses— Include a minimum of three differential
diagnoses and include how you derived at each diagnosis in accordance with DSM-5-TR
diagnostic criteria 20 to >17.0 pts
Excellent 90%–
100%
The response thoroughly and accurately documents the results of the mental status exam….
Response lists at least three
distinctly different and detailed possible
disorders in order of priority for a
differential
diagnosis of the family in the assigned case study, and it provides a thorough, accurate, and detailed
justification for each of the
disorders selected. 17 to >15.0 pts
Good 80%–89%
The response accurately documents the results of the mental status exam….
Response lists at least three
distinctly different and detailed possible
disorders in order of priority for a
differential
diagnosis of the patient in the assigned case study, and it provides an accurate
justification for each of the
disorders selected. 15 to >13.0 pts
Fair 70%–79%
The response documents the results of the mental status exam with some vagueness or
innacuracy…. Response lists at least three
different possible disorders for a
differential
diagnosis of the patient and provides a
justification for each, but may contain some vaguess or
innacuracy. 13 to >0 pts
Poor 0%–69%
The response provides an
incomplete or inaccurate description of the results of the mental status exam and/or
explanation of the differential diagnoses. Or, assessment documentation is missing.

20 pts
Criteria Ratings Pts
• Case formulation• Treatment plan that
includes psychotherapy interventions 25 to >22.0 pts
Excellent 90%–
100%
Case formulation is thorough, thoughtful, and demonstrate
critical thinking….
The assignment includes an accurate, clear, and complete
treatment plan for the client family that includes psychotherapy
interventions. The response demonstrates thoughtful
consideration of the client family’s situation and
culture. 22 to >19.0 pts
Good 80%–89%
Case formulation demonstrates
critical thinking….
The assignment includes an accurate, clear, and complete treatment plan for the client family that
includes psychotherapy interventions. 19 to >17.0 pts
Fair 70%–79%
Case formulation is somewhat general or does not demonstrate critical thinking….
The assignment includes a
treatment plan for the client family that includes psychotherapy
interventions but is somewhat general or contains small
inaccuracies. 17 to >0 pts
Poor 0%–
69%
The
assignment provides a vague and/or inaccurate description of the case formulation and treatment plan for the
client family. Or, many of the required elements are missing.

25 pts
• A psychotherapy genogram for the family 20 to >17.0 pts
Excellent 90%–
100%
The assignment includes an accurate, clear, and complete genogram of the client family. The documentation
style is consistent and a key is
provided. 17 to >15.0 pts
Good 80%–89%
The assignment includes an accurate genogram of the client family. The documentation
style is consistent and a key is
provided. 15 to >13.0 pts
Fair 70%–79%
The assignment includes a genogram of the
client family but is somewhat limited or contains factual
inaccuracies or
inconsistencies in documentation style. 13 to >0 pts
Poor 0%–
69%
The genogram provided is vague or contains many inaccuracies. Or, the genogram is missing.

20 pts
Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well- developed ideas, flow
logically, and demonstrate continuity of ideas. Sentences are carefully focused—
neither long and
rambling nor short and lacking substance. A clear and
comprehensive purpose statement and
introduction are provided 5 to >4.0 pts
Excellent 90%–
100%
Paragraphs and sentences follow writing standards for flow, continuity, and clarity A
clear and comprehensive purpose statement, introduction, and conclusion are provided that
delineate all required criteria. 4 to >3.0 pts
Good 80%–89%
Paragraphs and sentences follow writing standards for flow,
continuity, and clarity 80% of the time….
Purpose,
introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 to >2.0 pts
Fair 70%–79%
Paragraphs and sentences follow writing standards for
flow, continuity, and clarity 60%–
79% of the
time Purpose,
introduction, and conclusion of the assignment are vague or off topic. 2 to >0 pts
Poor 0%–69%
Paragraphs and sentences follow writing standards for
flow, continuity, and clarity
<60% of the time No
purpose statement,
introduction, or conclusion were provided. 5 pts
Criteria Ratings Pts
which delineate all required criteria.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation 5 to >4.0 pts Excellent 90%–100%
Uses correct grammar, spelling, and punctuation
with no errors. 4 to >3.0 pts
Good 80%–
89%
Contains 1 or 2 grammar,
spelling, and punctuation errors. 3 to >2.0 pts
Fair 70%–79%
Contains 3 or 4 grammar,
spelling, and punctuation errors. 2 to >0 pts
Poor 0%–69%
Contains many (≥5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font,
spacing, margins, indentations, page numbers,
parenthetical/in-text
citations, and reference list. 5 to >4.0 pts
Excellent 90%–
100%
Uses correct APA format with no errors. 4 to >3.0 pts
Good 80%–89%
Contains 1 or 2 APA format errors. 3 to >2.0 pts
Fair 70%–79%
Contains 3 or 4 APA format errors. 2 to >0 pts
Poor 0%–69%
Contains many (≥5) APA format errors.

5 pts

Total Points: 100