Pertinent History

ST, a 45 years old Caucasian male, had a family business he was running before and was doing well financially until his family business was impacted by hurricane Barry about one year ago that caused a family lifestyle change. ST lost his business, house, other valuable properties, and the primary source of income. ST relocated with his family to the current residential area but has not recovered from the impact of his loss, including financially. The loss of business and finances has a significant impact on ST, emotionally and otherwise. ST has disturbances in his sleeping patterns, loss of interest in prior social activities and friends. The financial restraint brought about some tensions in the family. ST was diagnosed with depression. Due to excessive worry and lack of proper care, ST has a new diagnosis of hypertension and diabetes and uses diet and exercise to manage them. ST verbalized feelings of worthlessness and loss of prestige due to his inability to provide his family’s same exotic lifestyle.

ST is currently working as a sales representative in a car dealership; is living in an apartment that he is renting with his family. ST reports it is a struggle to make ends meet because he makes much less than what he makes from his lost business. ST has a serious concern that he may lose his wife also. ST has a wife (MT)and three children. MT is a stay-at-home mom of 3 children; IT is 15 years old; LT is 11 years old, and NT is eight years old. MT has never worked since being married to ST. MT takes care of the house’s responsibilities, including school run, assisting the children with school assignments, and sports activities. Things have been moving on smoothly until after ST lost his business. Lack of financial flow and providing basic needs have strained their relationship. MT is 39 years old, with no significant medical history. MT is threatening to leave the relationship if ST cannot provide for her and the children to stabilize them. IT was attending private school from Pre-K after her father lost his business and source of income. Due to financial strain, IT is now attending public school with her other siblings. IT is experiencing challenges adjusting to their new lifestyle, relocating to a new residential area, starting a new school, and making new friends. IT has a loss of interest in sports and other pleasurable activities. The COVID-19 pandemic and the transition to online school compounded the idea of meeting and maintaining new friends. IT whines a lot on the ideas of not seeing her old friends. IT reports she does not think she belongs to the new school and that her family does not deserve to be living in their current residential home and community/environment. IT reports anxiety, feelings of depression and isolation, difficulty falling and staying asleep, poor appetite, and easily irritability. Both parents have significant concerns since the IT verbalization of suicidal ideation with no active plan. Both parents gave consent for the family to participate in psychotherapeutic treatment but do not wish for IT to be on medications at this time.

Diagnosis: Major Depressive Disorder.

The client meets the DSM-5 criteria for major depressive disorder. According to DSM-5, the client must present a minimum of the five of the following symptoms that have been present for a minimum of 2-weeks period or more: unhappy disposition, no interest in activities that previously brings joy, inability to sleep at night time, unintentional weight loss or gain, lack of energy, motivation, drive with frequent thoughts of deaths (American Psychiatric Association, 2013). The client with a major depressive disorder may present with recurrent suicidal ideation without a specific plan, a suicide attempt, or suicidal ideation with a specific plan for committing suicide (Halverson, 2019). IT met the criteria for this diagnosis.

Diagnosis: Adjustment Disorder.

According to the DSM-5, clinical symptoms or behaviors client manifest is evidenced significantly by the following: apparent dysfunctions in the manner the client interacts and associates comfortably with others socially, occupationally, academically, or other daily vital functional areas (American Psychiatric Association, 2013). Adjustment disorder is the inability to adapt emotionally and behavior-wise in response to attributable psychosocial stressors following a severe stressful unexpected life such as family discord, divorce, and business crisis. The symptoms include the inability of the client to readjust quickly. The client responds to the stressor in a manner that is out of the ordinary that individuals, socially or culturally, would typically react to a stressor in daily challenges or difficulties that will lead to impairment in daily functioning (O’Donnell et al., 2019).

Treatment: Solution-Focused or Cognitive Behavioral Therapy (CBT)

Cognitive-behavioral therapy (CBT) is the first-line treatment for depression. CBT is direct and time-limited that involves about 10 to 20 therapeutic sessions. Clients who present with depression usually present with irrational distorted negative opinions, thoughts, and views about themselves, the world, and the future that manifest in the form of emotional, mental, and behavioral challenges. CBT strengthens the client in developing behavioral strategies and cognitive restructuring to overcome and replace the negative distorted thoughts and maladaptive behaviors with positive thoughts and attributes (Wheeler, 2014). Interpersonal therapy (IPT) is a psychotherapy approach with a time limit of 16 therapeutic sessions to treat clients with major depressive disorder. According to Halverson (2019), IPT is less intricate structurally than cognitive and behavioral approaches.

The treatment for adjustment disorders can be a combination of counseling sessions utilizing cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) to reduce stress. The therapist combining both therapeutic approaches helps the client find strategies to establish support and emotional stabilities to readjust and overcome permanent stressors/challenges. The short-term therapeutic approach reassures the client that the challenges are for a short while, and there are chances of recovery with possible favorable positive outcomes.

Ethical & Legal Implication

As professionals, maintaining confidentiality during counseling therapy is vital. We must always maintain their privacy. As a Psychiatric Health Mental Nurse Practitioner (PHMNP), one is under obligation to diagnose accurately and treat presenting symptoms appropriately and effectively. The PMHNP must put under consideration the client’s cultural beliefs and ethnicity during an in-depth assessment. The client’s involvement in developing treatment plans is necessary, and the PMHNP must consider the client’s perception of the illness and ensure a detailed understanding of the diagnosis when planning treatment.

GROUP THERAPY PROGRESS NOTE

Client: IT Date: 10/18/2020

Group name: Process group Minutes: 50

Group session # 3 Meeting attended is #: 3 for this client.

Number present in group 4 of 4 scheduled Start time: 1000 End time: 1100

Assessment of client

1. Participation level: ❑ Active/eager ❑ Variable ❑ only responsive ❑ Minimal ❑ Withdrawn

2. Participation quality: ❑ Expected ❑ Supportive ❑ sharing ❑ Attentive ❑ Intrusive

❑ Monopolizing ❑ Resistant ❑ Other: Minimizing

3. Mood: ❑ Normal ❑ Anxious ❑ Depressed ❑ Angry ❑ Euphoric ❑ Other: _______________

4. Affect: ❑ Normal ❑ Intense ❑ Blunted ❑ Inappropriate ❑ Labile ❑ Other: Guarded

5. Mental status: ❑ Normal ❑ Lack awareness ❑ Memory problems ❑ Disoriented ❑ Confused

❑ disorganized ❑ vigilant ❑ Delusions ❑ Hallucinations ❑ other: Command hallucinations

6. Suicide/violence risk: ❑ Almost none ❑ Ideation ❑ Threat ❑ Rehearsal ❑ Gesture ❑ Attempt

7. Change in stressors: ❑ less severe/fewer ❑ Different stressors ❑ More/more severe ❑ Chronic

8. Change in coping ability/skills: ❑ No change ❑ Improved ❑ Less able ❑ Much less able

9. Change in symptoms: ❑ same ❑ Less severe ❑ Resolved ❑ More severe ❑ Much worse

10. Other observations/evaluations: Tearful and anxious during therapy

In-session procedures:

 Introduction of the practitioner to the clients

 The Practitioner discussed with clients about their week since the last meeting.

 Clients denied any major incident or behavioral issues at home since the last session

 Clients verbalized still feeling depressed, and coping skills have not been that effective.

 Clients were encouraged to reflect on the session and ask questions.

Homework:

1. Clients identified coping skills; exercise, meditation, and deep breathing exercises.

2. Journaling your stressors.

3. Talk more about where you picture yourself in the future.

Other Comments: ____________________________________________________________________________

_____________________________________________________________________________________

Signatures: Ol PMHNP-student.

Date: 01/5/2021.

Client Two

Pertinent History:

Client AI is a 15-year-old Hispanic American male who presents for counseling with his mom and boyfriend. The client reports angry at his dad for leaving mom and abandoning the children. The client reports recurrent suicidal ideation by overdosing on a chemical substance. The client reports a lack of energy, drive, motivation, and difficulty getting up from bed in the morning. The client reports sometimes he can go for one week without maintaining personal hygiene. Patient reports racing thoughts, frequency change in his mood, generalized muscle ache, and irritability. The patient reports low concentration that is affecting his performance in school. The patient endorses a loss of interest in living. The patient reports continuous thoughts of killing himself with a plan and intent that started two years ago but grew worse three days ago. The patient reports he attempted to kill himself by drinking fifteen hard liquor shots in less than twenty minutes. The patient was admitted to PHP after medical intervention. The patient denied prior suicidal attempts. The client had a diagnosis of anxiety and depression eight months ago.

The client is a 15-year-old male that lives in houses with his mom and dad. The client has two siblings, a sister that is 17 years and a brother that is 13 years, who are both in high school and junior high school. The client plays basketball and guitar for music. The client denies alcohol, tobacco, or illicit drug use but occasionally smokes marijuana when feeling depressed. The client appears well-groomed, honest insights into the situation, and shows no interest in anything during process group sessions. AI is currently on Abilify 20 mg PO daily, Buspar 20

mg PO BID, Trazodone 50 mg PO at bedtime, Vistaril 25 mg PO QID PRN.

Differential diagnosis: Major depressive disorder (MDD) recurrent, severe without psychotic features

According to the American Psychiatric Association (2013), DSM-5 has different criteria to define depression. These symptoms must be present such as depressed mood most of the day, as verbalized by the client (e.g., feels sad, empty, hopeless), or other people will note the observation (e.g., appears tearful). AI meets the criteria for MDD diagnosis because he presents with these symptoms. AI struggles to keep up with the basic daily needs of maintaining personal hygiene, difficulty getting out of bed. Life stress triggers and a sense of overwhelming triggers MDD as the client verbalized dad leaving the house and abandoning them to their mom. Fried et al. (2015) stated that depression diagnoses tend to increase when much stress and life feel overwhelming.

Solution-Focused or Cognitive Behavioral Therapy (CBT)

Cognitive-behavioral therapy (CBT) will be ideal for AI. According to Gajic-Veljanoski et al. (n.d), CBT is structural therapeutic psychotherapy the therapist recommends in the treatment of clients presenting with symptoms/diagnosis of major depressive disorder (MDD) and generalized anxiety disorder (GAD). CBT involves using coping strategies and positive interventions that share a common belief that cognitive factors influence mental, emotional, and psychological disorders. The essence of the CBT treatment approach, according to Hofmann et al. (2012), maintains that irrational distorted cognitive thinking will result in emotional dysfunction and behavioral problem. CBT treatment aims to help the client change the pattern of reasoning or behaviors responsible for the maladaptation and instability to positive coping mechanisms and strategies.

Legal and Ethical Implications related to counseling

The PMHNP, as part of integral professional practice, are expected to maintain confidential information the client reveals. The client trusts the practitioner and has confidence that sensitive information revealed during therapy is maintained. The fundamental practice of psychotherapy is maintaining confidentiality without which the client may not reveal sensitive personal information during a therapy session (Avasthi & Grover, 2013).

Group Therapy Progress Note

Client: AI Date: 10/18/2020

Group name: Process group Minutes: One hour

Group session # 4 Meeting attended is #: 4 for this client.