Family therapy

PRACTICUM EXPERIENCE TIME LOG AND JOURNAL TEMPLATE

Introduction

The purpose of this week’s journal entry is to discuss the two clients that I have observed and counseled this week during my practicum experience, who have attended the same family session and Group Therapy. The Progress Notes of the family session will be documented in accordance to this week’s learning Resources. The clients are described and identified with their pertinent history and medical information, including prescribed medications and using the Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition (DSM- 5), to explain and justify my diagnosis for the two clients and to explain any legal and / or ethical implications related to the counseling of the two clients

Documentation Skills to Examine Family Therapy Sessions

Documentation skills are essential skills required to examine Family Therapy Session. Documentation responsibility could be overwhelming considering the workload of therapist and advance practicing nurse performing psychoeducation and psychotherapy for individuals and groups of patients and clients. The documentation includes client’s notes, referrals, billing, treatment plans, and collaterals. To examine the family sessions effectiveness, it involves the development of session checklist, learn about the State’s documentation laws and rules, complete session notes with client’s, schedule note writing time, and set phone hours (Walter, I. R., 2016). According to Bowen’s theory, family is the natural system of relationships playing an important role in guiding clinical approach and psychotherapeutic care of the client and providing required intervention for patient care (Papero, D. V., 2014).

Client 1 Observed and Counseled this week during the Family Therapy

The client, LT, is a 13-year-old Caucasian female, a teenager, who lives with her father who had been diagnosed as a bipolar individual several years before the girl was born. The client was admitted to the acute care unit. The client’s chief complaint is missing school, waking up sad and constantly getting into argument with the father; having self-inflicted pain by hitting arms with the backscratcher until bruised. She indicated “I like to feel the pain”. The client presented with MDD, ADHD, SI and Self harm and diagnosed of Bi-polar, mixed severe without Psychosis. The client denies violence/assault, sexual aggression or victimization and elopement risk. History of hospitalization from age 12. The client reports feeling unstable and depressed, having her mood and attitude shifts frequently during the day.

The client was admitted with symptoms of increased anxiety, mood swing and Self-harm. The client indicated low academic engagement with low academic grades. Client reports of a sad news from her best friend which prevented her from adhering to medication regimen for four (4) days. Client indicated that her friend was impregnated by her uncle on multiple occasions which resulted in three (3) miscarriages. She reports that her friend could not tell her parent because she did not trust them for micromanage her like she has no voice.

During the session, LT reports that her parents loved her unconditionally and make all the resources available for her. According to the client, it took a toll in her until she was able to discuss with her dad’s stepmother and her therapist.

Current Triggers: Client reports increasing anxiety, mood and self-harm due to the sad news that she had bottled up for a period of time about the pregnancy and miscarriages of her best friend. In addition to this is the sudden mood swing and attitude change during the day which is of unknown etiology.

Current Medications: Client, LT is currently taking Trazodone 100mg PO QHS for Insomnia. Vyvause 20mg PO QAM for ADHD – on hold for psychosis. Hydroxyzine 12.5mg PO TID/PRN for anxiety. Quetiapine 25mg PO BID for mood. Escitalopram 20mg PO Daily for depression.

Past Medical History: Client reports no diagnosed medical history.

Past Surgeries: Client denies any past surgical experience

Substance use: Client denies the use of Tobacco, Alcohol, Marijuana, or any illicit drugs.

The Client was discharge to out-patient therapy to help her with motivation, planning, assignments, setting goals, trust, impulsive thought process, distorted thought, depression and anxiety, time management, activities of daily living, ability to complete a task without distraction, increase her self-confidence, believe and coping skills.

Justification of Diagnosis

Client LT presented with MDD, SI, and Self harm having a past psychiatric diagnosis of ADHD, and Bi-polar; current diagnosis is MDD, Severe Recurrent without Psychosis. The diagnosis for my client is according to DSM 5 is MDD - major depressive disorder Severe recurrent w/o psychosis. The client having five (or more) of the symptoms in criteria A, and meeting the criteria B and C. According to DSM -5, Criteria A –depressed mood, daily, and nearly every day as evidenced by the subjective reports of sadness, feeling of emptiness, and hopelessness or irritable mood (found in adolescents or children) or as observed by others; insomnia or hypersomnia nearly every day, fatigue or loss of energy nearly every day, feeling of worthlessness, excessive or inappropriate guilt, poor concentration or indecisiveness, lack of interest or pleasure in almost all activities most of the day, or nearly every day; significant weight loss, recurrent thoughts of death, suicidal ideation without specific plans or suicidal attempts with specific plans (American Psychiatric Association, 2013). Depression (major depressive disorder) is one of the common and universal mental illness affecting people’s feeling, thinking, and acting with emotional and physical problems, and inability to function appropriately. In addition, depression affects people of all ages irrespective of race, ethnicity, color, or backgrounds (Parekh, R., 2017; and the National Institute of Mental Health [NIMH], 2018; Rosenthal & Burchum, 2018).

Legal and Ethical Implications Related to Counseling Client

There are legal and ethical implications to counseling clients and family in a family session and group therapy session. Individual privacy and family confidentiality is crucial to patient’s care. The mental Healthcare Act 2017 (MHCA 2017), emphasized on patient’s right with regards to mental illness (PWMI) and the ethical and the legal responsibilities of mental health professionals and care providers; patient’s right in mental illness and disorders is the fundamental rights of human beings. The difference in legal requirement for individual therapy and group or family therapeutic care is not too far apart because vulnerable individual and family has to be closely considered and accommodated as well. Patient’s rights translated into the ethics of psychiatric care respect patient’s autonomy, the principles of non-maleficence, beneficence, and justice, client’s confidentiality and disclosure. Also patient’s boundary violations as well as the informed consent and involuntary treatment are necessary (Bipeta R., 2019).

Client 2 Observed and Counseled

The client, DA, is a 14-year-old Caucasian female, a teenager living with her Stepfather and mother and with her four (4) brothers. The client presents with depression and suicidal attempt of medication overdose and she was taken to the Emergency hospital and later transferred to the acute care unit after stabilization. The client has suffered from hopelessness, anxiety, and worry since 8 years of age, and she has been on Melatonin since 6 years of age. She was diagnosed of sexual abuse and mental anguish since parents were separated or divorced. The client’s chief complaint is that she is upset with her mother and stepfather. After dinner, they watched movies and went to bed and things just went down from that point. She lost her “cool” as reported though she indicated that she should have handled it better. The current diagnosis is MDD Severe, Recurrent w/o Psychosis.

The client admitted that her mother is controlled by the stepfather and she does not have time for the children. She added that mother always pay attention to her job and the husband. The client added that she is in a “grabby” school indicating that nobody likes the school, and nobody likes her. Client has history of two (2) episodes of physical fights at school and she confess during the therapy that “I want a freaking attention”. The Client, DA, added that the stepfather is creepy. She complained of having no data on phone and her mother is unable to provide data on her phone as well. Her mother promises her of meeting her needs but will never fulfill her promise. The client, DA busted into weeping during session. She indicated that she must work hard for everything she gets. She prefers to go home and stay in her room and talk to friends on phone. She feels her mother is not sensitive to her life and needs as a mother.

The father was present at the family therapy where he has indicated that the client has made two (2) suicidal attempts in the past because she does not know how to let out her anger. The father confirmed that the children are not happy with their mother indicating “why the pride and problems?” that the life of the children are on the line, He affirmed that the children is upset with the mother and the stepfather.

During the therapy, it was noted that it worth allowing DA, the client to have opportunity to live with the father temporarily. The father has his own issues but promised to be in the therapy with her on frequent basis. The complexity of their experience is the fact that mother got the custody privilege of the children because the father failed to show up in the court; therefore, intensive family therapy is required.

Past Medical History: Client reports no past medical history or disease.

Past Surgeries: No past surgical problems

Substance use: Client reports no use of substances like tobacco, Alcohol, and Marijuana.

The client was discharged to go home with her mother though it was not a pleasing outcome for the father and the client.

Justification of Diagnosis

Based on the client’s diagnosis, the DSM 5 is MDD - major depressive disorder Severe recurrent w/o psychosis must have five or more of the symptoms in criteria A, criteria B and C. DSM -5, Criteria A includes depressed mood, daily, and nearly every day as evidenced by the subjective reports of sadness, feeling of emptiness, and hopelessness or irritable mood commonly found in adolescents or children noted by others, insomnia or hypersomnia, fatigue or loss of energy nearly every day, feeling of worthlessness, excessive or inappropriate guilt, poor concentration or indecisiveness, lack of interest or pleasure in almost all activities most of the day, or nearly every day; significant weight loss, recurrent thoughts of death, suicidal ideation without specific plans or suicidal attempts with specific plans (American Psychiatric Association, 2013).

References

American Academy of Child and Adolescent Psychiatry. (n.d.). Ethical issues in clinical practice. Retrieved from https://www.aacap.org/AACAP/Member_Resources/Ethics/Ethics_Committee/Ethical_Issues_in_Clinical_Practice.aspx

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental health disorders (5th ed.). Washington, DC: Author

Bipeta R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

National Institute of Mental Health (NIMH). (2018). Depression. Retrieved from https://www.nimh.nih.gov/health/topics/depression/index.shtml

Papero, D. V. (2014). Assisting the Two-person System: An Approach Based on the Bowen Theory. Australian and New Zealand Journal of Family Therapy. 35(4).

Parekh, R. (January, 2017). Depression. American Psychiatric Association (APA). Retrieved from https://www.psychiatry.org/patients-families/depression/what-is-depression

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.

Walter, I. R. (2016). 5 Tips for Keeping Up with Therapy Paperwork. Family Therapy Basics. Retrieved from https://familytherapybasics.com/blog/2016/11/7/5-tips-for-keeping-up-with-therapy-paperwork

Wheeler, K. (Eds.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.