Assessing Client Progress
COMPREHENSIVE CLIENT FAMILY ASSESSMENT 6
Comprehensive Client Family Assessment and Genotype
Comprehensive Client Family Assessment
Comprehensive family assessment is the systematic process of guiding decision-making by recognizing, evaluating, and assessing factors that concern children, youth, and their families. A psychiatric and Mental Health Nurse Practitioner (PMHNP) does assessment or a therapist from the moment when a client and or family come to the notice of the social services system-or before-until the review of cases begins. A comprehensive family analysis is driven by family-centered, culture-competent research concepts. Wherever possible, families are seen as supplying their children with the greatest care and security, the family is the focus of all the effort, and family members are deeply engaged in the creation and execution of the assessment. A Comprehensive Assessment explains the psychological, physical, and psychosocial state and needs of the person in more detail. It defines support gaps that are met and by whom; resources that have not been made available; barriers to entry to the support; and programs that are not well organized. The assessment also measures the strengths and weaknesses of the client including families and other nearby services that can be considered through service health assessment and diagnosis.
Demographic Information
RA is a 49-year-old white male, employed at Home depot, and married to his wife Hannah for 20years. He is blessed with 4 children 3 boys and 1 female. One of the children succumbed to cancer 2 years ago after battling with the illness for seven years.
Presenting Problem
Mr. RA requested to be taken through psychological therapy after a series of depression, stress, and anger management events that were creating unrest in the family. Due to his current state, Mr. RA has to keep some distance from his wife and children to maintain harmony and avoid actions that may cause physical and psychological unrest in the family. RA needs to recover from depression, stress, and uncontrolled anger to live a normal life with his family members and ensure his three children do not grow fearing him.
History of Present Illness
Mr. RA has never had episodes of depression, stress, or anger before. The conditions surfaced two years ago after the passing on of his son due to cancer. Ever since the death of his son, he has been finding it difficult to control his emotions and be amidst his peers in his place of work. This led to him losing his job, a factor that is contributing to his present condition.
Past Psychiatric History
The client has never had any psychiatric illnesses before. The first incidence started two years ago. However, the client stated that his father and mother had a history with depression that came about, as they were getting older. His parents have however not had any experience with anger management.
Medical History
The client has had a previous therapy session that involved intervention from substance use addiction. This happened in his early life before getting into marriage.
Substance Use History
The client has had a history of substance use. During his youthful stage of life, the client was addicted to alcohol. The addiction took place for almost six years after which he decided to seek medical attention. Currently, the client does not smoke or drink.
Developmental History
Both the client and his family members are having a normal developmental history. Despite the history of substance abuse from the client and the period of loss of a loved one, the client and his family are still having normal development.
Family Psychiatric History
The client did not outline any information to do with a family psychiatric history.
Psychosocial History
The client and his family had a period of abnormal psychosocial life after the passing on of the client’s son. The passing on of one of their own disturbed the client, his wife, and children, and until today, they always remember the impact he had on the unity and peace of mind within the family.
History of Abuse/ Trauma
The client did not record any history of abuse on himself. However, he mentioned a scene where he created fear to one of his sons after a domestic issue. Due to anger mismanagement, the son felt frightened and mentioned how dangerous his father can be.
Review of Systems
Gen: Reject the presence of chills and fever
ENT: Reject the existence of ear tubes and tinnitus.
Cardiopulmonary: The client denies chest pain, orthopnea, or dyspnea.
GI: The client confirms a decrease in appetite.
Skin: The client rejects occurrences with skin bruising or injury.
Neuro: Rejects muscle flaw and paraesthesia
Psych: Accepts SI/HI ideation
Physical Assessment
The client and his family members are physically okay and stable. The client reported that physical statute has not been interfered with despite the psychological issues affecting the family.
Mental Status Exam
The client looks calm composed and cooperative during the assessment. His wife and kids are also composed and are not distracted with fantasies and thinking of anything beyond the clinical assessment. However, the client is disturbed and starts to continuously talk with a high tone when aspects of family unity and relationship with his children are asked. Generally, the client’s anger and stress are accelerated with matters affecting the peace of the family.
Differential Diagnosis
• Adjustment disorder with depressed mood
• Post-traumatic stress disorder
The client is diagnosed with adjustment disorder with depressed mood when they cannot adjust to a new situation or event in life due to feeling overwhelmed and hopelessness for example death of a loved one (Casey, 2014). In this case, the client described that he started feeling stressed and depressed with episodes of anger after their son's death. The goal of therapy is to help the client to adjust to the new norm through acceptance. According to Hsiao et al. (2014), the client's response to external stressors is brought by acute or chronic adjustment disorder. In his parents' case, they fell into depression during their old age due to difficulties in adapting to their new lifestyle.
Case Formulation
The client was referred to psychotherapy sessions at the individual, to talk and express his feelings. During therapy sessions, the client revealed that he felt hopeless, shocked, and saddened by his son’s death. He added that his son brought a sense of unity in the family, which he feels he now lacks. Our psychotherapy sessions will aim at helping the client cope and accept the current situation.
Treatment Plan
• Psychotherapy with client
• Family therapy and group therapy
• Cognitive Behavioral therapy
Although antidepressants can be used to treat the condition, psychotherapy remains the best option for people with adjustment disorders. It is structured and organized with clearly defined goals, measurable objectives, and a given timeline for completion. According to Carta et al. (2009), therapy helps clients identify stressors to develop strategies to deal with them. Patients have the active role of coming up with solutions to problems that they face. The process both empowers and leads to commitment on the part of the patient.
References
Carta, M. G., Balestrieri, M., Murru, A., & Hardoy, M. C. (2009). Adjustment Disorder: epidemiology, diagnosis, and treatment. Clinical Practice and Epidemiology in Mental Health, 5(1), 1-15.
Casey, P. (2014). Adjustment disorder: new developments. Current Psychiatry Reports, 16(6), 451.
Hsiao, F. H., Lai, Y. M., Chen, Y. T., Yang, T. T., Liao, S. C., Ho, R. T., ... & Jow, G. M. (2014). Efficacy of psychotherapy on diurnal cortisol patterns and suicidal ideation in adjustment disorder with depressed mood. General hospital psychiatry, 36(2), 214-219.