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Family Assessment and Psychotherapeutic Approaches

College of Nursing-PMHNP, Walden University

NRNP 6645: Psychotherapy with Multiple Modalities

June 13, 2021

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Abstract

As providers, it is vital to be open-minded, if you are not aware or do not understand a person’s

culture, show your patients respect. Be engaged, respectful, and ask questions. Learn from your

patients, this helps develop a rapport. As providers we are obligated to provide optimal care, if

we feel a patient’s needs are out of our scope, the client should be referred to a provider that can

give them the help they need and deserve (Nichols & Davis, 2020).

The purpose of this paper is to provide documentation and a psychiatric comprehensive

assessment of a patient and family during a family therapy interview that highlights differences

in a multicultural family, respecting cultural norms and differences, and develop an

individualized treatment plan.

Keywords: Family therapy

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Family Assessment and Psychotherapeutic Approaches

Subjective:

CC (chief complaint): “I like to learn to live on my own and not depend on the kids.”

HPI: A 40-year-old female (Patti) and her five children (Sheela age 24, Sharleen aged 23

and present today, Shireen age 21 recently reunited with family, Armin Jr. age 18, and Sam age

15), of Iranian descent, has been in individual and family therapy for the last 18 months. Patti

came to the clinic related to chaos in the home after her daughter was finally reunited with the

family after ten years. The family initially had rejoiced and celebrated, and after a few weeks,

Shireen began to tell her mother and siblings the emotional, physical, and sexual abuse at the

hands of her father. She blamed and felt abandoned by her mother. Patti needed necessary

surgery to both her feet after an injury, that has now left her disabled and with chronic pain. The

additional burden of surgery and disability has increased tension and stress in the home. Patti

lives with her two sons; her daughters live on their own. Shireen recently moved out, marrying

someone the family does not know, with little contact. Mother speaks and sees Sheela and

Sharleen daily. Patti has increasingly felt alone, depressed, hopeless, and helpless wanting her

daughters to stay and help her at her home. A psychiatric provider has been referred for a

medication evaluation.

Past Psychiatric History:

General Statement: Patti and her family began therapy 18 months ago after daughter

Shireen reunited with the family after 12 years of separation. Shireen shared significant abuse

she experienced, learning the trauma she went through brought on many emotions of the family

including blame, guilt, shame increasing stress on the family.

Caregivers: N/A

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Hospitalizations: Patti denies any past psychiatric hospitalizations or history. The patient

has no history of substance abuse or residential treatment. Patti denies suicidal and homicidal

ideation, denies hallucinations. The patient has had two-foot surgeries secondary to arthritis,

hammer toe, and severe plantar fasciitis with no relief for over 2 years, patient in hospital

overnight after each surgery.

Medication trials:

Zoloft 50 mg every morning for depression, with limited relief. Will feel helpless and

hopeless three to four days a week. The patient is tolerating the Zoloft and has recently been

increased to 100 mg daily.

Patti reports no adverse effects of Zoloft.

Naproxen 500 mg twice a day

Psychotherapy or Previous Psychiatric Diagnosis:

Patti has been receiving individual and participated in family therapy over the last 18

months. Shireen came once and has stopped attending and refuses to continue at this time. The

family has come to therapy together five times, to heal and move on together.

Patti had surgery in the last 6 months and is no longer able to work related to the

deteriorating condition of her feet that arthritis has caused. This has led to being unable to work

at home often alone. She is experiencing being independent and providing, what she has done for

so long. This has caused stress, increased anxiety, and depression for Patti.

Therapy over the last several months has also uncovered differences in the bicultural

situations. Patti is wanting the care provided to her as in the Iranian culture, where she is

dependent on her children. The children living in America for the last 12 years are more

Americanized and have adapted to the culture, with their own lives leaving less time for Patti.

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Substance Current Use and History: Patti drinks 16 ounces of caffeinated beverages

daily. She denies smoking or drinking alcohol.

Family Psychiatric/Substance Use History: Patti denies any substance or alcohol

abuse. She is unaware of any of her family has any abused drugs or alcohol. Her husband drinks

large amounts daily, has not received treatment for alcoholism. Patti denies any psychiatric

history in herself or her family.

Psychosocial History: Patti was born in Luristan Iran, raised by her mother and father.

She had no siblings. At 14, her parents arranged for her to be married to Armin Ali, a 25-year-old

foreman of a prominent automobile company in Tehran. Patti moved to Tehran and had five

children with Armin. Patti gave birth to Sheela at the age of 16, Shareen at age 17, Shireen at age

19, Amir Jr at age 22, and Sam at age 25. Patti stayed at home working in the home and raising

the children while Amir worked and provided for the family.

When Sheela and Shareen were 11 and 12, it was discovered they had medical conditions

that needed treatment in the United States. Patti applied for visas to come to the United States.

She was able to take all her children but Shireen. Amir encouraged Patti to go, he would look

after Shireen and come to the United States later. Once Patti arrived, she was able to get the

needed medical treatment for her daughters and started making a home for her family She

believed Amir would later come with Shireen. After years went by, this did not occur, only letters

of how she needed to raise her children. Patti did not want to return to Iran. She struggled with

leaving Shireen behind and afraid for her other children if she returned. Patti had been abused

emotionally, physically, and sexually by Amir from the time they were married. Patti and her

four children made a home in the United States, Patti worked two jobs, but also made time to

attend school functions and volunteer at her children’s school. Patti continued to work at

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bringing Shireen to the United States, it took several years. She was finally able to bring her,

Shireen was 18 when she arrived, and the family celebrated. After a few weeks, Shireen began to

share her trauma of emotional, physical, and sexual abuse by her father. Patty struggled to hear

the information, she was aware, as Amir would treat her the same way, she would tell him to beat

her and not her children. Shireen was angry and blamed her mother. Patti pursues help with

therapy to work through the guilt and shame of the trauma.

Medical History: Hammer toe, bilateral great toes, arthritis, plantar fasciitis

Current Medications:

Zoloft 100 mg every morning for depression and anxiety

Naproxen 500 mg twice a day

Tramadol 100 mg twice a day as needed for severe pain.

Allergies:

No known drug allergies

No known seasonal allergies

No Known food allergies

Reproductive Hx: The patient is a Gravida 5 para 5. The patient denies any abortions or

miscarriages. The patient has been celibate for the last 12 years since arriving in the United

States. The patient denies any sexually transmitted infections, started menses at age 14. The

patient has menses every month without any significant issues or concerns.

ROS: Provided by a medical provider.

GENERAL: Alert and orientated x 4. No weight loss, fever, chills, weakness, or fatigue.

HEENT: No hearing loss, sneezing, congestion, runny nose, or sore throat.

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SKIN: No rash or itching. Incisions on bilateral great toes healed. The incision on

bilateral heels healed, with no redness or bruising.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. Regular rate

and rhythm, no murmurs, no rubs, no gallops. No palpitations or edema.

RESPIRATORY: No wheezes, rales, or rhonchi. No shortness of breath, cough, or

sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal

pain. No guarding or rebound tenderness.

GENITOURINARY: No burning on urination, urgency, hesitancy, or odor.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia. No change in

bowel or bladder control.

Cranial Nerve 2: vision is grossly accurate.

Cranial Nerve 3,4,5,6: motor movements appear normal.

Cranial Nerve 7: facial muscles appear symmetrical.

Cranial Nerve 8: hearing is adequate for her age.

Cranial Nerve 9-12: swallows without difficulty.

MUSCULOSKELETAL: No muscle and back pain, chronic pain in bilateral feet.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria

or polydipsia.

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Physical exam:

Vital signs: B/P: 126/78, P: 88, Height: 63 inches, Weight: 225lbs, BMI: 39.9 (NIH.gov,

2020).

General: Alert and oriented to self, time, location, and situation.

Head: Symmetry

Eye: extraocular movements are intact, normal conjunctiva. Vision: shortsighted, glasses

worn.

Ears: Symmetry. Normal hearing.

Neck: Symmetry. No swelling or palpable mass noted. Throat: Symmetry. Oral

mucosa is moist.

Neck: Full ROM. Carotids no bruit or JVD.

Chest/Lungs: Lungs are clear to auscultation. Respirations are non-labored.

Heart/Peripheral Vascular: Normal heart rate, regular rhythm, no edema noted.

Abdomen: Round and large. Bowel sounds present in all four quadrants. Negative

tenderness.

Genital/Rectal: No abnormalities. Menses started at 15 and are regular.

Musculoskeletal: Normal ROM. muscle weakness due to physical inactivity

Neurological: Cranel Nerves II-Xll grossly intact.

Skin: No clubbing or cyanosis.

Toes: Bilateral great toes, incisions healed.

Objective:

Diagnostic results:

CBC: within normal

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Assessment:

Mental Status Examination: A 40-year-old Iranian female, appearing stated age. The

patient is alert and oriented to self, place, time, and situation. Patient cooperative, engaged in

conversation. Patient grooming clean, although shirt tight fitting. Speech is clear, Iranian accent

with average tone. During the interview, when upset or arguing with the daughter, her voice

becomes louder. Thought process goal-directed and logical. No noted flight of ideas,

hallucinations, or delusions noted. No abnormal motor activity noted. The patient’s mood is

depressed and anxious, affect blunted at times. The patient denies being suicidal or homicidal

currently. The patient’s short-term and long-term memory intact, good insight and judgment,

with good concentration. The patient has no legal history, arrests, and no pending charges. Eye

contact is fair throughout the interview.

Differential Diagnoses:

Adjustment disorder with depressed mood – Patti’s children are growing up; she is

feeling alone. She states when she is lonely, she feels hopeless and helpless. She is wanting her

children to stay with her, having a difficult time adjusting to them not home as much. She has

also had recent surgeries in the last 4 months, and she is adjusting to not being as independent as

she was before with mobility and chronic pain issues. Patti is exhibiting feelings of sadness and

hopelessness in response to three identifiable stressors; recent surgeries and children moving out

of the home, and grief and guilt of past trauma her daughter experienced. The patient meets the

criteria as a primary diagnosis (APA, 2013).

Depressive disorders not due to another medical condition; grief, PTSD. Patti has

had depressive episodes prior to her surgeries, she has been in therapy for the last 18 months, she

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has had traumatic events in her life including abuse, and loss. It is important to determine if the

medical condition is associated with depression. It is necessary to examine if an episode of

depression occurred prior to medical illness, the medical condition promotes depression, and if

the symptoms after the start of the medical condition stabilized (APA, 2013). A panel consisting

of psychiatric health professionals strongly recommends interventions for patients with post-

traumatic stress disorder to include cognitive behavioral therapy, cognitive therapy, and eye

movement desensitization and reprocessing (EMDR). Medications recommended include Prozac,

Paxil, Zoloft, and Effexor(“Summary of the Clinical Practice Guideline for the Treatment of

Posttraumatic Stress Disorder (PTSD) in Adults,” 2019).

Depressive Disorder Due to Another Medical Condition (chronic pain) – It is noted

that after Patti’s surgeries, she became more depressed, with feelings of hopelessness, and

needing her daughter increased(“Mother and Daughter: A Cultural Tale.”, directed by

Anonymous, 2003). Patti’s independence decreased, and she was no longer interested in

activities that impacted her mobility. According to recent studies, chronic pain has been

connected to family dynamic changes, causing family tension. As the family burden occurs, an

individual can become depressed and have increased difficulty managing their pain (Boone &

Kim, 2019). Patti does not meet the criteria listed for this diagnosis, she does find pleasure with

her children, friends, and three dogs. Relational dynamics, interactions, and symptoms causing

pain to influence an individual’s pain. People can be either positively or negatively affected

depending on the emotional support they are feeling. people with pain and their partners (Tankha

et al., 2020).

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Reflections:

Case Formulation and Treatment Plan: include psychotherapeutic interventions that

take into consideration the family’s culture and current situation.

Diagnostic studies:

Order thyroid panel. The thyroid and hormones play a significant role within the brain

and how the brain functions. According to research, individuals that suffer from either

hypothyroid or hyperthyroid conditions, anywhere from 30-70% suffer from symptoms of

depression or anxiety (Erensoy, 2019).

Referrals:

 Coordinate with community behavioral health agency for the patient to engage in services

including a psychiatric provider for medication management and peer specialist to engage

in activities including group and art therapy at the clinic.

 Coordinate with a primary care provider for continuous management of medical

management

 Referral to a pain specialist to evaluate treatment options for chronic pain of bilateral

feet.

 Referral to physical therapy for increased mobility and prevent decompensation.

 Referral to a nutritionist for assistance with weight management increase self-confidence

and promote community engagement.

Therapeutic interventions:

Discussed the risks, benefits, side effects, alternatives of medications, and the target

symptoms with the patient. Side effects of Zoloft reviewed include weight gain, nausea,

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vomiting, increased thirst, headache, weakness, increase in suicidal ideation, and

constipation(Drugs.com, 2020). Reviewed significance of not discontinuing any

medication without discussion with a provider, and to contact the provider with any

adverse effects.

 Strongly discouraged mixing of any medications. Discussed mixing medications

including over the counter, herbal supplements, alcohol, and illegal substances may be

detrimental. Discussed the importance of abstaining from alcohol and illegal substances,

as they may have a damaging influence on a patient’s mental health, depression, sleep

cycle, and physical health.

 Scheduled appointment with a psychiatric provider in 3 days.

 Scheduled appointment with a primary provider in 7 days.

 Confirmed with a patient, she has phone numbers for her children, the crisis line,

emergency services, and to go to the closest emergency department if she starts having

feelings of self-harm, suicidal or homicidal thoughts.

The patient’s questions were answered. The patient verbally stated that she understands

the discussion and is in agreement with the treatment plan. Pt signed the treatment plan

willingly.

Reflections:

This was an interesting case, with many layers, and many things that attributed to Patti’s

depression. Sandy, the therapist working with the family has worked with the family, doing well

throughout the last eighteen months. Although the family is currently stuck with moving

forward, I feel Sandy worked with the family with progress and moving forward. I liked the

approach of having a team to examine and bring forward other ideas and perspectives to help the

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family heal and move forward. The family initially came in related to reuniting a family, as time

went on tensions of multicultural differences were also addressed. It is obvious that although the

family is having some struggles, they love and care for each other very much. The children want

their mothers to have a productive and independent life. It is important to address and respect the

family’s differences in their beliefs. An important goal for the family is to find a routine that

works for both mother and her adult children. It is important that both mother and children feel

supported, and both have their independence.

The articles I have attached are considered scholarly as evidence by, dated within the last

five years, peer-reviewed, and obtained from the Walden Library.

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References

APA. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5). [MBS Direct].

Retrieved from https://mbsdirect.vitalsource.com/#/books/9780890425572/

Boone, D., & Kim, S. Y. (2019). Family Strain, Depression, and Somatic Amplification in Adults

with Chronic Pain. International Journal of Behavioral Medicine, 26(4), 427–436.

https://doi.org/waldenulibrary.org/10.1007/s12529-019-09799-y

Drugs.com. (2020). Interaction checker. Drug interaction report. Retrieved June 12, 2021, from

https://www.drugs.com/interactions-check.php?drug_list=1476-0,3266-0,1573-0,11-

12,276-0&types%5B%5D=major&types%5B%5D=minor&types%5B

%5D=moderate&types%5B%5D=food&types%5B

%5D=therapeutic_duplication&professional=1

Erensoy, H. (2019). The association between anxiety and depression with 25(OH)D and thyroid-

stimulating hormone levels. Neurosciences (Riyadh, Saudi Arabia), 24(4), 290–295.

https://doi.org/.waldenulibrary.org/0.17712/nsj.2019.4.20190028

“Mother and Daughter: A Cultural Tale.”, directed by Anonymous. (2003). Masterswork

Productions [Video]. Alexander Street. https://video.alexanderstreet.com/watch/mother-

and-daughter-a-cultural-tale.

Nichols, M., & Davis, S. D. (2020). The essentials of family therapy (7th ed.). Pearson.

NIH.gov. (2020, October 26). Standard BMI calculator. National heart, lung and blood institute.

https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Summary of the clinical practice guideline for the treatment of posttraumatic stress disorder

(PTSD) in adults. (2019). American Psychologist, 74(5), 596–607.

https://doi.org/waldenulibrary.org/10.1037/amp0000473

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Tankha, H., Cano, A., Corley, A., Dillaway, H., Lumley, M. A., & Clark, S. (2020). A novel

couple-based intervention for chronic pain and relationship distress: A pilot study. Couple

and Family Psychology: Research and Practice, 9(1), 13–32.

https://doi.org/waldenulibrary.org/10.1037/cfp0000131.supp (Supplemental)