Select two clients you observed or counseled this week during a family therapy session. Note: The two clients you select must have attended the same family session.
Then, address in your Practicum Journal the following:
Describe each client (without violating HIPAA regulations) and identify any pertinent history or medical information, including prescribed medications.
Using the DSM-5, explain and justify your diagnosis for each client.
Explain whether solution-focused or cognitive behavioral therapy would be more effective with this family. Include expected outcomes based on these therapeutic approaches.
Explain any legal and/or ethical implications related to counseling each client.
Support your approach with evidence-based literature.
Running head: GROUP THERAPY PROGRESS NOTE 1
GROUP THERAPY PROGRESS NOTE 2
Introduction
Mental disorders may damage the ability of individuals to maintain their marital and social relationships. Marriage offers a variety of benefits such as general support and economic status maintenance. Divorce related to mental disorder affect the economic life of the couples as well as their social well-being of the children. Further, mental disorders increase the possibility of divorce as well as lowering the chances of marriage. Married couples with higher levels of stress, psychiatric disorders are more likely to divorce (Nichols and Tafuri, 2013). Consequently, the importance of couples experiencing some mental disorders to seek professionals help to avoid divorce cannot be undermined. The purpose of this assignment is to assess the two clients in a group therapy and outline the legal and ethical implications associated with the therapy.
History of the Presenting Case
The case family consisted of Jake, a 29-year old Caucasian and his wife Jenna a 26-year old also Caucasian. Both have lived together for 7 years with two children aged 6 and 4 in a small town in Missouri. However, Jake is an Army veteran who returned from his two-year tour of duty in Iraq 1 year ago. At the war zone, he worked as a communication specialist in charge of alerting the army convoy any potential danger. Upon his return to continental America, Jake received a medical discharge based on his physical and mental injuries. Also, the he had suffered from second-degree burns from spontaneous explosive device blast that instantly killed one of his best-friend.
In the session, Jake self-reported anxiety, insomnia, nightmares, flashbacks, and fear of social places. He reported flashbacks happened a few days ago when he was driving with wife to a grocery store. He stated he saw another car coming at a higher speed then theirs. Jake became diaphoretic and increased the driving speed drastically while screaming loud for the wife to take cover under the dashboard. In fear, Jenna also screamed out for her husband to stop the car. They did not understand the flashbacks were triggered by burning rubber, which was a reminder of the traumatic incident in Iran. Further, he reported the fear that he could face a divorce due to his declining condition. He said “he died long time ago” while in Iraq and has deep feeling of shame as he remembers how he accidentally killed an innocent child who would have been the same age as his old son. Besides, he has been experiencing frequent irritability, poor attention, and poor concentration.
Conversely Jenna, reported an intense fear because of the threats of her husband whom she describes as the reason to many issues in the family. Jenna has been undergoing emotional volatility, and insomnia, pervasive anxiety. Since, Jake returned from Iran, said she as lost some weight dealing with her husband’s violence behavior. Jenna said she warned the husband if he fails to seek help; she would take the children and leave him. She claimed her husband no longer marriage values they share before going to military. This makes her feel worthless, she said. She voiced concerns related to the conflict they have been having lately. she admitted at times she has been having suicidal thoughts.
Clinical Impression of the clients:
Jake appeared to be well-built, fit, walked stiffly and quickly. Even though the husband appeared orderly, his clothing masked signs of being fearful. Nevertheless, there was no evidence of delusion, hallucinations, and other psychosis symptoms (Mojta et al., 2014). Conversely, the wife, reported signs of anxiety such as sadness, irritation, agitation and rage.
Diagnostic Criteria
Jake presented with complaints of not maintaining normal daily interactions with his family. He struggles with psychological, emotional, and social relations. His clinical presentation suggests he meets the DSM-5 criteria for post-traumatic stress disorder (PTSD). The DSM-5 manual list several criteria that the client must meet to be diagnosed with the PTSD. The criterion A outlines that the client must be involved in life threatening event, threated serious injury or sexual violation (American Psychiatric Association, 2013). According to the manual, the client must also have experienced or witnessed the event or experienced repeated exposure to distressing details of the event. Further, the client must experience at least one of the symptoms associated with the traumatic event such as recurring and involuntary memories of the traumatic event, dissociations such as flashbacks, repeated upsetting dreams related to the event, and strong body reactions such as increased heart rates and sweating (American Psychiatric Association, 2013).
Finally, the manual states, a client with PTSD exhibit at least two negative changes in moods such as irritability, negative emotional state such as rage and shame, and loss of interest in activities that once enjoyed. Jake meets the criteria for PTSD because of the re-experiences of flashbacks and nightmares, hyperarousal such as rage storms, avoidance, and irritability. Likewise, the client suffered grief from the loss of his friend and a child he killed accidentally during the mission. Nevertheless, it is important to rule out other conditions such as major depression disorder characterized by limited concentration and limited concentration as well as diminished interest in activities and insomnia. More than 1.8 million American soldiers are deployed in Iraq each year (Wheeler, 2014). Most of these soldiers are exposed to unpleasant experiences and trauma which can potentially lead to unstable family dynamics following one’s return from military operations. Despite their continued contribution to the community, many veterans commit suicide each year due to PTSD.
Conversely, Jenna presented with symptoms of major depression disorder (MDD). She voiced the complaints of insomnia, persistent anxiety, and feeling of worthlessness. According to DSM-5 criteria, the client experiencing MDD must present with at least five of the following symptoms; depressed moods, sleep disturbances, loss of energy, and feeling of worthlessness, significant weight change, and loss of interest in almost all activities (American Psychiatric Association, 2013). L’Abate (2015) stated, women who partners are away on military deployment are at great risk of developing mental condition. The review also, found that women whose spouses are in military experience increased anxiety and stress associated with isolations. The level of anxiety and depression on the women is worsened when their spouses return from the military operations with changed behaviors. That explains why the rate of military spouses tend to ask for divorce following their partners’ return from combat zone.
Legal and ethical Implications
Marriage therapists tend to face more ethical challenges than individually oriented therapists. The American Counselling Association (ACA) code of ethics the counsellors requires therapists to ensure they offer quality of care regardless of the diversity (Natwick, 2017). Legally, the counsellors or therapists must maintain the confidentiality of the clients’ information. ACA require a written informed consent and a verbal discussion of rights and responsibilities in counselling relationship (Natwick, 2017). The challenge is to isolate an individual from couple counselling. While it is critical to assess for family dynamics such as abuse and dependent disorders, the therapist can find themselves compromised by the promises made in good faith.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
L’Abate, L. (2015). Highlights from 60 years of practice, research, and teaching in family therapy. American Journal of Family Therapy, 43(2), 180–196. doi:10.1080/01926187.2014.1002367
Mojta, C., Falconier, M. K., & Huebner, A. J. (2014). Fostering self-awareness in novice therapists using internal family systems therapy. American Journal of Family Therapy, 42(1), 67–78. doi:10.1080/01926187.2013.772870
Natwick, J. (2017). Family ties: Tackling issues objectivity and boundaries in counseling. Counseling Today, 59(10), 16–18.
Nichols, M., & Tafuri, S. (2013). Techniques of structural family assessment: A qualitative analysis of how experts promote a systemic perspective. Family Process, 52(2), 207–215. doi:10.1111/famp.12025
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer.
Journal Week Two
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This week’s journal will concentrate on two clients engaged in the family sessions. This journal reflects on past medical history and psychiatric diagnosis using the DSM-V criteria for diagnosing and treatment plan. Also, a discussion regarding any legal and ethical implications and the potential impact on therapy and outcomes with the treatment plan will be addressed.
The clients are in therapy for supportive marriage counseling. The couple were married for 12 months, lives in off-post housing along with the wife’s mother. The husband is currently receiving individual therapy for Adjustment Disorder with Depressed Mood for the past 90 days (Kreamer & Morris 2017). Following his counseling, the treatment plan includes marriage counseling with his wife’s husband to improve communication, adjusting to the culture, new living situation and mother in law being part of the household, adding tension to the marriage.
The couple has been in counseling for one month, and both are seeking interventions for a successful marriage. Currently, strategic family counseling model is being used to address behaviors and emotions regarding mother in law, who wants her daughter to divorce and leave the husband. This has caused stress and strain on the marriage, particularly on the husband, being accused of “adultery” by the mother in law.
In this couple’s counseling, the therapist utilized a developmental model. The Developmental Model of couple’s therapy facilitates both partners to recognize one another feelings or problems within the couple’s dynamic. Also, it teaches methods to convey the current state of stressors within the relationship while working on coping mechanisms and increasing communication skills ((Kreamer & Morris 2017). The counselor encourages more communication, which helps the couple work through barriers in the marriage. This will assist in creating a more reliable, mature and emotional bond to each other (Kreamer & Morris 2017).
Client one- Asian descent, 27-year-old husband Chinese American, English is his primary language; however, speaks fluent Mandarin. He is a specialist E-4, active duty in the US Army. There are no current medical problems. He is “happy” with his new wife and wants to have children soon. He denies any legal issues and has received several awards, including Army Accommodation last year.
Client two- Asian descent, 25-year wife, Chinese immigrant, Mandarin is her primary language, speaks fluent English, she migrated to the US after getting married. She is a nursing student, on a marriage Visa, no legal issues. Her mother moved in the past six months.
Psychiatric history: The husband was diagnosed with Adjustment Disorder with Depressed Mood, 90 days ago. He was reported, having difficulty sleeping, unable to concentrate, feeling “depressed” all the time, since his mother in law moved in. He reports the mother in law is constantly berating him, starting arguments and making accusations of “adultery” against him, which can cost, the marriage and his career. Client one was placed on fluoxetine 10mg daily for symptom relief (Xia et al. 2018). Client reports prior to the mother in law moving in, “everything was great”. Client two is aware of the strife between her mother and her husband. She wants to remain married and trust her husband. Client one admits to “having girlfriends before marriage,” has been faithful since the engagement. Client two ‘feels overwhelmed” all the time (Xia et al 2018).
Diagnosis
Adjustment Disorder with depressed mood 309.0 (F43. 21): Client one, He reports, not wanting to get out of bed and feeling overwhelmed and anxious about coming home and continuously thinking failures in his marriage. He cannot concentrate at work and received a counseling statement for missing deadlines (APA 2013).
Adjustment Disorder With anxiety 309.24 (F43.22) Client two, feeling overawed anxious, nervousness, worried all the time (APA 2013).
Family/Couples Therapy
The student APRN was allowed consent to attend the couple therapy session by both the husband and wife.
Client One (husband) is Alert and Oriented x 4 spheres and willing to participate and engaged in the meeting, as evidenced by the completion of his homework from the previous session. He was task with expressing three positive personal features, and he brought to the marriage. She was anxious during a review of her homework. He feels the stress level is higher over the past 90 days. He had exhibited a few coping skills, such as playing a game to destress. He is using deep breathing techniques and boundaries when his mother in law starts an argument, and this has been beneficial in the past. His mood is consistent with the situation, and he states he implements meditation into his evening routine, before entering the house. His affect is anxious. he denies Suicidal/ Homicidal Intent
Client two (wife) is Alert and oriented x 4 spheres; she completed her assignment on three positive features, she likes to cook, especially for her husband’ looks at the floor when the husband mentions her mother. Client two, she likes attending class and learning new ideas.
Session
.At the initiation of the session, both clients agreed, signed consent, and was notified of HIPPA policy and educated on confidentiality (Roca et al. 2016). The objective and treatment plan were discussed with the couple and both agreed with the plan. The goal is to improve communication for an improved, fulfilling relationship. It is vital to have all involved parties state the purpose of the sessions to ensure all parties agree (Barnett & Jacobson 2019). During the initial first minutes of the therapy session, both clients agreed to respect one another boundaries. The husband was referred to couple’s therapy, per his provider, since the source of his stress is an outside source.
Asking the couple open questions allows the patients to discuss what they deem essential in divulging (Barnett & Jacobson 2019). Using open-ended questions cultivates an environment to address what barriers the clients are facing day to day, allowing the intervention resolution or plans to overcome the obstacles on a unified front.
At the close of the session, each client was asked to describe and rate their mode, asked was there anything they wished to discuss, both denied. Both clients deny suicidal/homicidal intent (Barnett & Jacobson 2019).
References
Association, A. P. (2013). Diagnostic and Statistical Manual of Mental Disorders. doi: 10.1176/appi.books.9780890425596
Barnett, J. E., & Jacobson, C. H. (2019). Ethical and legal issues in family and couple therapy. In B. H. Fiese, M. Celano, K. Deater-Deckard, E. N. Jouriles, & M. A. Whisman (Eds.), APA handbooks in psychology®. APA handbook of contemporary family psychology: Family therapy and training (p. 53–68).American Psychological Association. https://doi.org/10.1037/0000101-004
Kreamer, S., & Morris, E. (2017). What is the efficacy of medication versus CBT or both for the treatment of depression in adolescents?. Evidence-Based Practice, 20(12), E13-E14.
Nichols, M., & Davis, S. D. (2020). The essentials of family therapy (7th ed.). Boston, MA: Pearson.
Roca, R. P., Charen, B., & Boronow, J. (2016). Ensuring staff safety when treating potentially violent patients. Jama, 316(24), 2669-2670
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer.
Xia, W., Zhou, R., Zhao, G., Wang, F., Mao, R., Peng, D., … & Fang, Y. (2018). Abnormal white matter integrity in Chinese young adults with first-episode medication-free anxious depression: a possible neurological biomarker of subtype major depressive disorder. Neuropsychiatric disease and treatment, 14, 2017.
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