Family Therapy

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What Is Family Therapy? Techniques & Interventions

Client Family Assessment Progress and Privileged Notes for a 68 Year-Old Hispanic Female with Psychosis

The progress note written after psychiatric evaluation and assessment serves to provide a summary of the patient’s condition, the diagnosis, the goals of care, as well as the plan of care itself. According to Cameron and Turtle-Song (2002), the best way to write down a progress note is to summarize it in a SOAP format. The patient is 68 year-old patient MA who is Hispanic and female. She has symptoms of psychosis and presented with marked auditory hallucinations. She is currently undergoing a combination of cognitive restructuring psychotherapy in the form of cognitive behavioral therapy (CBT) concomitantly with pharmacotherapy and family therapy (Corey, 2017; Wheeler, 2014). It is after these sessions that the progress and privileged notes are written by the psychiatric-mental health nurse practitioner or PMHNP. Available current evidence states that a specialized form of CBT combined with pharmacotherapy and family therapy delivered in a timely manner (early) will significantly reduce the psychotic symptoms and reduce the future risk of the same by 50% or more (Haram et al., 2019). The purpose of this paper is to document patient MA’s progress and privileged notes as would have been written by the PMHNP after therapy sessions.What Is Family Therapy? Techniques & Interventions

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Progress Note for Patient MA

Subjective

On presentation, the main complaint from patient MA was an increase in psychosis symptoms marked by auditory hallucinations. She is hearing voices that are prompting her to want to cause harm to herself and even others. She has a previous history of the same symptoms and has had several previous admissions for the same. At home, she stays with her son. She has however been quite uncooperative with the clinician and would not reveal further details about her condition or her previous admissions. She has a rich past psychiatric history with many previous admissions with an ongoing diagnosis of chronic psychotic mental illness that is unspecified. Her medical history is also significant in that she has multiple comorbidities namely congestive heart failure (CHF), hypertension (HTN), and chronic, obstructive pulmonary disease (COPD). She has also previously suffered seizures and a cardiovascular accident or CVA. She does not have any significant surgical history or any allergies. Her current medications are:

Acetyl salicylic acid (ASA) 81 mg orally every day for the management or secondary prevention of the coronary artery disease (CAD), and
Rivaroxaban 10 mg orally daily for anticoagulation and management and secondary prevention of a CVA and myocardial infarction or MI (Rosenthal & Burchum, 2018; Katzung, 2018).
There is significant substance use history in that patient MA admits to using cocaine before from the time that she was 18 years old. She however would not reveal when she last used the substance. She also smokes cigarettes and admits to using pot since she was 16 years old. Patient MA is Christian and used to like playing football. Her developmental history from childhood is unremarkable. She developed normally like any other child. There is no family history of psychiatric conditions on her part. There is also no family history of drug or substance abuse. She however has an extensive psychiatric history and is known for non-compliance to treatment and therapy. She however has no history of trauma or violence in her records. Of all her systems reviewed, she reports occasional migraine headaches, a loss of appetite, general body weakness, and hallucinations of an auditory nature.

Objective

Patient MA appears dishevelled and unkempt with poor bodily hygiene. Her vital signs are T: 36°C; BP: 102/74 mmHg; RR: 17; PR: 70; Height: 6’0”; Weight: 86.35 lbs; and BMI: 11.7 kg/m2 (she is underweight). She is not appropriately dressed for the time of the day or the prevailing weather. She is confused with very poor insight and judgment. Her speech is latent with slurred rhythm and soft volume. The speech content is also impoverished. She is resigned, paranoid, and avoids eye contact during the interview. She displays impatience with repetitive motor movements like pacing u and down without staying still. Self-reported mood is “sad” while observed affect is dysphoric. There is congruency between the mood and the affect. She has hallucinations and experiences both homicidal and suicidal ideation. Her thought process is tangential with the content being represented by preoccupations and hallucinations. Insight is fair but judgment is poor.What Is Family Therapy? Techniques & Interventions

Assessment

From the subjective and objective information, the differential diagnoses given to patient MA are:

Psychosis with predominantly auditory hallucinations (Griswold et al., 2015; Sadock et al., 2015; APA, 2013).
Substance (opioid-induced) psychotic disorder with hallucinations (Griswold et al., 2015; Sadock et al., 2015; APA, 2013).
Substance (alcohol-induced) psychotic disorder with hallucinations (Griswold et al., 2015; Sadock et al., 2015; APA, 2013).
Plan

Patient MA has a history of non-compliance to treatment. For this reason, she requires a multifaceted approach to the management of her psychosis. She is therefore put on psychotherapy (CBT) and pharmacotherapy. Her family is also put on family therapy to enable them cope, especially her son with whom she lives. The treatment plan is therefore as follows:

Quetiapine (Seroquel) 200 mg orally at bedtime for 5 months (Stahl, 2017)
Mirtazapine (Rameron) 15 mg orally at bedtime for 2 months (Stahl, 2017)
Clonazepam (Klonopin) 1 mg orally twice a day (Stahl, 2017)
Cognitive behavioral therapy (CBT) weekly for 12 weeks (Corey, 2017)
Family therapy every week for 8 weeks (Corey, 2017)
The above treatment modality is efficacious and evidence-based as has been proved through available scholarly literature (Haram et al., 2019; Rosenthal & Burchum, 2018; Stahl, 2017). It is hoped that progress will be made especially with regard to treatment compliance and other mutually agreed-upon goals. This treatment is a modification of the treatment that she was already on by the inclusion of psychotropic medications and psychotherapy.

There is no relevant psychosocial information change from the initial assessment. Patient MA still lives with her son and he basically forms her social support system. Safety issues include the possibility of the patient hurting herself and so there should be a caregiver dedicated to keeping her company throughout the day. There have not been any clinical emergencies yet, and the medications that the patient has been taking before this current treatment plan have been given as ASA and rivaroxaban. The management of patient MA will definitely require interprofessional collaboration as with any other psychiatric patient. For instance, this patient is underweight and will require nutritional counselling together with the son by a registered dietician. The therapist’s recommendation is that the patient be put in involuntary commitment until he condition is stabilized. This is in view of the fact that she is not compliant with treatment and also has suicidal and homicidal ideation. These are valid and legal reasons for putting a patient like her under involuntary commitment. Patient MA has not agreed to this recommendation and that was not entirely unexpected. A referral to a mental health facility and a psychiatrist has been made to that effect so that the plan for involuntary commitment can be effected in line with the laws in the state. There are currently no termination issues as the client’s psychotherapy sessions are being paid for by the Centers for Medicare and Medicaid Services under the Affordable Care Act (ACA 2010). The consent for involuntary commitment would be obtained from the son who is accompanying her and who is the only significant next of kin to patient MA that is known as at now. There has not been any information regarding abuse of patient MA as an elderly person, either at home or in the healthcare setting.

Privileged Note for Patient MA

Privileged notes are also referred to as psychotherapy notes. They are notes that would not normally be included in the medical records of a patient. The therapist writes these notes to assist her in making therapy decisions and also to remember which questions to ask the patient during the next therapy session. Legally, no one else has the right to access privileged notes. This includes payers and even the patient herself. As stated above, privileged notes are not part of the conventional medical records of the patient. Only the progress note falls under this category. The content of privileged notes cannot be included with the other clinical/ medical records for the simple reason that they may be inappropriate and only qualify as the therapist’s honest view and opinion about the patient and her condition. This kind of information cannot be shared with other interprofessional team members or even the payers like the CMS.What Is Family Therapy? Techniques & Interventions

During my practicum experience, I have seen that my preceptor uses privileged notes when offering therapy to her clients. On enquiring, she gave me the same reasons as have been explained above why these notes are ‘privileged’ and cannot be included together with the progress notes as the patent’s legal medical records. I asked her about the kind of information she might include in her privileged notes and she replied that these would be her personal opinions, her own observations, her own conclusions drawn from the assessment and interaction with the patient, any lingering or embarrassing questions she might have concerning the patient’s therapy and condition, and hypotheses she might have created based on the patient’s condition, therapy, and response to the management.

The privileged note written by the PMHNP as the therapist for patient MA in this case is as follows:

I strongly believe that this patient’s problem of drug and substance abuse goes deeper than I am being told. If she started abusing drugs at the tender age of 16, it is quite possible that she has tried many other drugs and substances apart from the cocaine and pot that she is revealing to me.
This reluctance of the patient to reveal more details about her past psychiatric history is worrying me. My honest opinion is that the memory of these events is traumatic for her and she would not wish to remember them. These are signs of PTSD and I am more than convinced that this patient may have suffered significant abuse as a child contrary to what they are letting me know.
I feel that the son with whom she lives is just embarrassed to divulge some details of his mother’s past. I do not know the best approach I can use to get this information out of him. I fear that I may offend him if I tell him what I think. What will he think if I am wrong in my assumptions? Indeed there is a real risk of jeopardizing the therapist-client relationship I have created with this family. They may lose trust and confidence in me.
Even though the patient’s son is showing compassion and care while at the clinic, I am almost convinced that this patient is neglected at home where she stays with the son. This may not be deliberate as the son may have just been overwhelmed with responsibilities. But how do I even broach this subject with the son? Will he not see me as becoming too intrusive? The lack of hygiene in the patient as well as the lack of compliance to medications and treatment point to a lack of a good social support network. The patient is also underweight; a fact that means that she is not being fed properly and with a balanced diet. These are critical and emotional issues that will require a lot of tact on my part to get down to.
Will the son agree if I suggest that after discharge from the involuntary commitment the mother should be taken to a nursing home? Will he agree to bear the additional cost?
References

American Psychological Association APA. Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Author.

Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286-292. https://doi.org/10.1002/j.1556-6678.2002.tb00193.x

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10th ed. Cengage Learning.

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Griswold, K.S., Del Regno, P.A., & Berger, R.C. (2015). Recognition and differential diagnosis of psychosis in primary care. American Family Physician, 91(12), 856-863. https://pubmed.ncbi.nlm.nih.gov/26131945/

Haram, A., Fosse, R., Jonsbu, E., & Hole, T. (2019). Impact of psychotherapy in psychosis: A retrospective case control study. Frontiers in Psychiatry, 10(204), 1-10. https://doi.org/10.3389/fpsyt.2019.00204

Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14th ed. McGraw-Hill Education.

Rosenthal, L.D., & Burchum, J.R. (2018). Lehne’s pharmacotherapeutics for nurse practitioners and physician assistants. Elsevier.

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11th ed. Wolters Kluwer.What Is Family Therapy? Techniques & Interventions

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.

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

Assignment 1: Practicum – Assessing Client Family Progress (Due in Week 8)

Learning Objectives

Students will:

Create progress notes
Create privileged notes
Justify the inclusion or exclusion of information in progress and privileged notes
Evaluate preceptor notes
To prepare:

Reflect on the client family you selected for the Week 3 Practicum Assignment.
Assignment

Part 1: Progress Note

Using the client family from your Week 3 Practicum Assignment, address in a progress note (without violating HIPAA regulations) the following:

Treatment modality used and efficacy of approach
Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the treatment plan for progress toward goals)
Modification(s) of the treatment plan that were made based on progress/lack of progress
Clinical impressions regarding diagnosis and or symptoms
Relevant psychosocial information or changes from original assessment (e.g., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job)
Safety issues
Clinical emergencies/actions taken
Medications used by the patient, even if the nurse psychotherapist was not the one prescribing them
Treatment compliance/lack of compliance
Clinical consultations
Collaboration with other professionals (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)
The therapist’s recommendations, including whether the client agreed to the recommendations
Referrals made/reasons for making referrals
Termination/issues that are relevant to the termination process (e.g., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)
Issues related to consent and/or informed consent for treatment
Information concerning child abuse and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
Information reflecting the therapist’s exercise of clinical judgment
Note: Be sure to exclude any information that should not be found in a discoverable progress note.What Is Family Therapy? Techniques & Interventions

Part 2: Privileged Note

Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client family from the Week 3 Practicum Assignment.

In your progress note, address the following:

Include items that you would not typically include in a note as part of the clinical record.
Explain why the items you included in the privileged note would not be included in the client family’s progress note.
Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why.
No Assignment due this week.

Assignment 2: Practicum – Week 5 Journal Entry (Continued–Submit This Week)

By Day 7

Submit your Assignment. Refer to Week 5 for additional guidance.

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What Is Family Therapy? Techniques & Interventions

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