NURS6665 COMPREHENSIVE INTEGRATED PSYCHIATRIC ASSESSMENT

SAMPLE 1

 

WEEK 1 INITIAL DISCUSSION POST

The YMH Boston Vignette 4 video, described a 16 year adolescent client who came into an outpatient clinic for a mental health assessment.  He was referred there by his mother and he reported he had no idea why he was there.  In the video, it was evident the client did not want to be at the appointment.  The provider used many techniques to engage the adolescent client.  Some techniques displayed in the vignette were helpful and some techniques should have been avoided.  The following post will answer four questions provided from the discussion board in relationship to the video.

What did the practitioner do well?

At the beginning of the session the provider informed the client about confidentiality.  Confidentiality is a cornerstone of healthy therapeutic relationships and effective treatment and is based upon the ethical principles of autonomy and fidelity (Wheeler, 2014).  Another positive is that the provider engaged the client by asking him about his views.  That indirectly communicates that the provider believes the client has his own thoughts and feelings. The client has a positive response to the engagement as he becomes more verbal and makes better eye contact.  Sadock, Sadock, and Ruiz (2014) reported once rapport has been established, many adolescents appreciate the opportunity to tell their side of the story (p. 1109).  Lastly, the provider asks about other people in the client’s life.  In doing this, the provider finds out that the client is more comfortable relating to his girlfriend and his coach. The client feels more comfortable talking about those relationships and becomes more genuine when talking about other relationships.

In what areas can the practitioner improve?

There were a few areas the provider could improve on.  When the patient states his mother thinks he has an “anger management” problem, the provider challenges him, saying that his mother must have a reason for thinking this. The provider’s tone of voice and facial expressions indicate that he is having some negative feelings about this patient. By taking the approach that challenges the client it alienates him.  In the vignette the client withdraws and looked down with his hands in his lap when the provider expressed that.  Learning to read a teen’s body language is an important skill.  A teen who is avoiding eye contact, mumbling words, or giving one word answers may be struggling with something, and providers can often help teens open up by acknowledging this discomfort (Tomescu and Ginsburg, 2012).

At this point in the clinical interview, any compelling concerns? If so, what are they?

At this point in the interview there are a few compelling concerns.  One being the provider doesn’t elicit strategies for the patient to communicate with his mother more effectively.  The patient says he doesn’t like it when his mother “keeps nagging him” to talk about his feelings. This can be viewed as a developmental issue as well as a family issue, as adolescent boys do not generally want to talk to their mothers about their feelings (Sadock, Sadock, and Ruiz, 2014). Although development does not occur in a linear stage, familiarity with the primary developmental themes and transitions of each age period provides an important context from which to view current symptoms (Sadock, Sadock, and Ruiz, 2014).  The provider should also recognize that the patient is saying that talking about his feelings is hard for him and he feels angry when he is pushed to try. The provider reflects and normalizes the patient’s aversion to talking to his mother by using humor. This resonates with the patient and helps him become more connected.

What would be your next question, and why?

The provider identified the client’s positive attributes, but the “at risk” behavior was not addressed.  I would assess substance use, abuse, and addiction.  I would start with a question from the CRAFFT screening tool “have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?”  Substance abuse or dependence can have a significant impact on psychiatric symptoms and treatment course (Sadock, Sadock, and Ruiz, 2014).  Substance use contributes sharply to the mortality related to injuries and violence, and to the morbidities of school failure, depression, and sexually transmitted disease acquisitions (Pollack, 2006).

References

Pollack, W. (2006). The “war” for boys: Hearing “real boys” voices, healing their pain.Professional Psychology-Research and Practice, 37(2), 190-195. Retrieved from Walden Library databases

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

Tomescu, O. & Ginsburg, K. R. (2012). Interviewing the adolescent: strategies that promote communication and foster resilience. In Emans, Laufer, Goldstein’s Pediatric and Adolescent

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.

YMH Boston. (2013c, May 22). Vignette 4 – Introduction to a mental health assessment [Video file]. Retrieved from https://www.youtube.com/watch?v=JCJOXQa9wcE

SAMPLE 2

What the Practitioner did Well

Sean is a 16 year old client who presented for evaluation. The practitioner after watching the YMH Boston Vignette 4 Video did some few good things.

• Firstly, he set up a comfortable relaxing environment for Sean.
• He told Sean all about the procedure of the therapy process; by explaining his privacy rights. When dealing with teenagers, using this approach will let them feel comfortable and at ease and ready for the therapy.
• The practitioner’s initial approach was honest when he made Sean to understand that whatever he says here will be private. Private except when it is absolutely necessary as an exclusion to confidentiality to disclose in the event that it might be a threat or harm towards Sean or others. This gave Sean enough confidence to feel free. Teenagers like their things kept secret and in confidentiality. Client confidentiality is the basis of a healthy therapeutic relationship and the therapist has an ethical and legal responsibility to protect the confidentiality and privacy of his/her clients ( Pope & Vasquez, 2016).

Areas to Improve on

There are also some few things that need improvement on. The practitioner did not greet or introduce himself to Sean. Not greeting or introducing oneself can always be seen as arrogance especially when culture has to be taken into consideration. Not greeting and introducing oneself can be negative and can sometimes cause a barrier to a successful therapeutic approach. It is always advisable to master the questions to be asked a client and let writing be very minimal. The practitioner could be seen writing during this interview, causing distractions  and communication breakdown. Comprehensive Integrated Psychiatric Assessment discussion essay examples – YMH Boston Vignette 4 video..

Sean does not like school but the practitioner did not ask about his school and why he hates school. More could have been gotten just by asking that question. Comprehensive Integrated Psychiatric Assessment discussion essay examples – YMH Boston Vignette 4 video. Another ignored spot was his relationship with his mother. The practitioner should have been able to get more from this too. Allowing Sean to participate by encouraging him to use his own words in describing his problem would have led to more information. As said and emphasized by Goldstein, & Findling (2006), an open inquiry followed by more focused questions later in the interview provides the most information and how a provider should also seek detailed descriptions of the behavioral or emotional symptoms and ask for specific examples of the behavior.

Another area where the practitioner needs improvement is to avoid asking leading questions. He asked Sean “I bet that really made you angry, right?” An obvious answer is “yes.” A better question would be, “How did you feel when that happened?

Compelling Concerns during the Clinical Interview

Sean’s deep rooted anger  towards his mom is a compelling concern. Knowing that Sean has this deep rooted anger should have led to more questions to find out why. Knowing that many teenagers do not like to confide in or talk to their mothers, the practitioner should not have seen it as a reason not to ask, but instead find out if Sean’s mother even  know about this deep rooted anger and why. Also, the practitioner should be concerned about the coach being his father figure. Where is his biological father, and how often if at all do they see each other, and why? Comprehensive Integrated Psychiatric Assessment discussion essay examples – YMH Boston Vignette 4 video.

Next Question and Reason Behind the Question

Just for curiosity sake, questions like what makes Sean angry, if angry does he feel like hurting himself or someone or not, if he likes his life, what he enjoys doing besides basketball and talking with his girlfriend, and also get more insight into his relationship with his girlfriend and its seriousness. His performance in school, questions like “what is going on at school that makes you hate it so much?” According to (American Psychiatric Association, (2013), struggling academically may indicate an inability to concentrate which may point to a psychiatric diagnosis such as depression, anxiety, or attention-deficit hyperactivity disorder. Comprehensive Integrated Psychiatric Assessment discussion essay examples – YMH Boston Vignette 4 video.

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

`           disorders (5th ed.). Washington, DC: Author.

Goldstein, A., & Findling, R. (2006). Assessment and evaluation of child and adolescent

psychiatric emergencies. Psychiatric Times, 23(9), 76-111.

Pope, K. S., & Vasquez, M. J. (2016). Ethics in psychotherapy and counseling: A practical guide. John Wiley & Sons.

 

SAMPLE 3

A Mental Health Assessment is one of the most important parts in diagnosing; it allows the provider to evaluate needs, level of impairment or detailed picture of what the person may need (Hill, 2014). Based on the YMH Boston Vignette 4 video:

What did the practitioner do well?  I feel the practitioner explained to the client of the right of protection/privacy, “A special issue concerning confidentiality is when the patient indicates that he or she intends harm” (Sadock, Sadock, & Ruiz, 2014). He did notify the client of his rights and everything is confidential unless there are any safety issues of the client discussing wanting to hurt him or others.

Also the practitioner was able to make the conversation at ease to understand why the client’s mother scheduled the appointment. I liked how he transitioned to find out more like why did he think his mom want him to come or if he has any support systems (coach and girlfriend) seeing he doesn’t feel comfortable talking to his mom, the practitioner also validated the client’s thoughts “you just want someone to listen and not be a parent”

In what areas can the practitioner improve?  Suggested in our reading from Kaplan & Sadock’s states of “Premature Advice” and “Judgmental Question/Statements” I feel the piece of how the client thinks his mom is just nagging and doesn’t listen to him.  I understand where the provider is trying to make it comfortable to get the client to talk but he never speaks how your mom is your parent and making sure he understands even at his older teen age she is doing what she is to be doing parenting not being a friend.  And encourage him to still talk to his “mom” and perhaps they can both work on communication of listening

At this point in the clinical interview, do you have any compelling concerns? If so, what are they?  Not really a compelling concern but I would like to see an overview of what the client wants to work on during his time, making reasonable goals possibly in communication with mom and/or work on coping strategies with his anger.

            What would be your next question, and why?  I would want to find out more of his temper/anger; how well can he control it, does he becomes physically aggressive (throw items, break things, hit/ punch people or objects), how does he control himself (at home or school).  If this maybe problem that can be solved with therapy like CBT or does he possibly need medication along with therapy.  “Anger control training (ACT) aims to improve emotion regulation and social-cognitive deficits in aggressive children. Children are taught to monitor their emotional arousal and to use techniques such as cognitive reappraisal and relaxation for modulating elevated levels of anger” (Sukhodolsky & et al., 2016).

 

 

 

Reference:

Hill,T. (2014). Preparing for a Mental Health Evaluation. PsychCentral. Retrieved from www.psychcentral.com

Sadock, B.J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11^th ed.). Philadelphia, PA: Wolters Kluwer.

Sukhodolsky, D. G., Smith, S. D., McCauley, S. A., Ibrahim, K., & Piasecka, J. B. (2016). Behavioral Interventions for Anger, Irritability, and Aggression in Children and Adolescents. Journal of child and adolescent psychopharmacology, 26(1), 58-64.

 

SAMPLE 4

What did the practitioner do well?

• Began the interview in a relaxed, non-structured manner to establish rapport and build therapeutic alliance.  Spoke in language appropriate to client’s developmental age. Addressed privacy concerns and limits to confidentiality.

In what areas can the practitioner improve?

• Greet client and introduce self; ask how the client wants to be addressed.
• Relieve client anxiety and diffuse tension/strangeness of the situation by asking how client feels about coming in; and by explaining the assessment process and duration of the interview.

At this point in the clinical interview, do you have any compelling concerns? If so, what are they?

• Interviewer does not clearly identify the reasons and factors leading to referral; does not obtain an accurate picture of the clients developmental function, nature, and extent of the behavioral issues, functional impairments, and/or subjective distress; and does not identify potential individual, family, or environmental factors that may be influencing difficulties. Comprehensive Integrated Psychiatric Assessment discussion essay examples – YMH Boston Vignette 4 video.

• Interviewer does not follow client’s lead and moves to questioning other topics (i.e. When asking about how client is doing in school, client responds with negative comment “Kinda sucks” but is not asked to elaborate by interviewer).  Interviewer switches back and forth between topics (i.e. school and leisure activity) that appears to provoke annoyance and confusion in client.

What would be your next question, and why?

• What would you like to see different from coming in today? Open-ended question that provides client time to tell their story.  Creates a level of comfort and helps to build/strengthen rapport; gives client sense that you are interested in listening.  Provides insight into what issues client views as most distressing Comprehensive Integrated Psychiatric Assessment discussion essay examples – YMH Boston Vignette 4 video.

References

Carlat, D. J. (2017). The Psychiatric Interview (4^th ed.). Philadelphia, PA: Wolters Kluwer. Sadock, B. J. & Sadock, V. A. (2003). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (9th ed.). Philadelphia, PA: Wolters Kluwer.

 

SAMPLE 5

 

What did the practitioner do well?

 

The practitioner started out the conversation by explaining the importance of confidentiality and what he can and cannot share with this adolescent’s parents. This creates a clear understanding for the patient and allows him to feel more comfortable to share information with the practitioner. Educating the patient on the importance of confidentiality and examples on when it must be broken to maintain safety and societal rights can help the patient establish trust in the provider (Sidhu & Srinivasraghavan, 2016).

The practitioner also did a good job at carrying the conversation and keeping the patient engaged as adolescents do not always like to share personal information with providers and adults in general. A patient’s motivation for treatment along with their interpersonal relationships, relationship with the provider, and any history of problems with the law can all affect a patient’s treatment progress and outcome (Landrum, 2015).

 

The practitioner used empathetic listening by restating and clarifying what the patient was saying and feeling. This can help to make the patient feel more validated with their feelings. He made good eye contact and nodded his head to let the patient know he was heard which is another nonverbal cue included in active listening. Active listening techniques improves patient and provider relationship and outcomes (Beck, & Kulzer, 2018).

 

In what areas can the practitioner improve?

 

The practitioner never introduced himself to the patient nor did he let the patient introduce himself. The first impression of a patient and a provider is crucial because if patients are going to discontinue services with a provider early, without achieving an expected outcome, it will most likely happen after the first visit (Wampold, 2015). It is human nature to make quick initial judgements of people after meeting them one time, and a proper and appropriate introduction can create that lasting desired impression.

 

The practitioner did not acknowledge the patient’s statements and tended to jump to the next question when initially asking the patient about his social life and what the patient enjoyed doing in his leisure time. I do understand it is important to get to the main reason and issues why the patient is being seen, however, when the patient was talking about school and basketball, the practitioner kept jumping to the next question without acknowledging what he had said. When the practitioner asked the patient how school was going and the patient replied, “it kinda sucks,” the practitioner did not even ask why it was not going well in his opinion, he just went onto ask another irrelevant question. I feel like the practitioner could have discussed more things that the patient liked and that made him happy before digging right into his problematic behaviors that his mother has accused him of.

 

At this point in the clinical interview, do you have any compelling concerns? If so, what are they?

 

The practitioner was still trying to establish a rapport during this interview, however, he did not try to help the patient recognize that his mother might just be trying to help him. The practitioner did a lot of validating the patient, which is good to an extent. The provider is still trying to establish a rapport with the patient and gain trust, however, if he continues to validate his behaviors, the patient may believe that he does not do anything wrong and will continue the negative behaviors. The provider must recognize that he can empathize with the patient and try to see where he is coming from but then suggest an opposing point of view for the negative behaviors. Making sure the patient is emotionally stable is an important first step before choosing a specific approach to address behaviors (Markowitz & Milrod, 2011).  The patient’s specific behaviors must be acknowledged by the patient himself as well.

 

What would be your next question, and why?

 

My next question would be asking the patient in what way he feels that his mother could communicate with him better in order to improve their relationship and potentially his problematic behaviors. I would also want to ask him how he could better respond to his mother and what he thinks he could do to change on his part as well. Family therapy might beneficial when trying to compromise and come up solutions on both the parent and child’s side. It may also help the mother and her son to see each other’s perspective when having a mediator to broaden each other’s perspectives. Family therapy is a good tool to use when collaboration is difficult and to allow the patient to feel like they have input and that they are being heard (Tuerk, 2012).

 

References

Beck, K., & Kulzer, J. (2018). Teaching Counseling Microskills to Audiology Students:

Recommendations from Professional Counseling Educators. Seminars in hearing, 39(1), 91–106. https://doi.org/10.1055/s-0037-1613709

 

Landrum, B., Knight, D. K., Becan, J. E., & Flynn, P. M. (2015). To Stay or Not To Stay:

Adolescent Client, Parent, and Counselor Perspectives on Leaving Substance Abuse Treatment Early. Journal of child & adolescent substance abuse, 24(6), 344–354. https://doi.org/10.1080/1067828X.2013.844088

Markowitz, J. C., & Milrod, B. L. (2011). The importance of responding to negative affect in

psychotherapies. The American journal of psychiatry, 168(2), 124–128. https://doi.org/10.1176/appi.ajp.2010.10040636

Sidhu, N., & Srinivasraghavan, J. (2016). Ethics and Medical Practice: Why Psychiatry is

Unique. Indian journal of psychiatry, 58(Suppl 2), S199–S202. H            ttps://doi.org/10.4103/0019-5545.196838

Tuerk, E. H., McCart, M. R., & Henggeler, S. W. (2012). Collaboration in family

therapy. Journal of clinical psychology, 68(2), 168–178. https://doi.org/10.1002/jclp.21833

 

Wampold B. E. (2015). How important are the common factors in psychotherapy? An

update. World psychiatry : official journal of the World Psychiatric Association (WPA), 14(3), 270–277. https://doi.org/10.1002/wps.20238

SAMPLE 6

 

Week 1 Main Post

Based on the YMH Boston Vignette 4 video, post answers to the following questions

Introduction

When a practitioner meets a client for the first time, it is crucial to building a therapeutic alliance. This alliance is important because it helps the clinician obtain a thorough psychiatric database, interview for diagnosis and negotiate a treatment plan with the client. According to Sadock, Sadock, and Ruiz, (2014), the initial encounter between the client and the clinician shapes the nature of the patient-client relationship which can have a profound influence on treatment outcome.

What Did the Practitioner do Well?

 

The first thing the practitioner did well was to address issues concerning confidentiality. Sadock, Sadock, & Ruiz, (2014), noted that confidentiality is crucial in the treatment process and it needs to be discussed with the client on multiple occasions. Starting the interview process by discussing confidentiality and exceptions when it can be broken is very important. When patients present to any healthcare setting, the healthcare provider must protect the client’s privacy. Confidentiality is vital in creating a therapeutic relationship and positive outcomes. The principle of autonomy gives the patient the authority to decide whom to reveal their medical information. Although patients have the right to their privacy, healthcare providers have the right to breach a patient’s confidentiality when they are a harm to themselves or others (Sori & Hecker, 2015).

Secondly, the question “what brings you in today” or “why d you think your mother wanted you to come in today” can help the therapist educate the client about the nature of the interview. Carlat (2012) noted that it is essential to educate the client about the nature of the interview because some clients come in with preconceived ideas while others may have no idea why they are talking to the practitioner. Thus, it is essential to ask the client if they understand the purpose of the interview. Lastly, I think asking the client about school and sports served as a jump-starting point and it made the client open-up more. The interview was conducted in a comfortable and confidential setting, and the interviewer appeared warm, courteous interested in the patient’s concerns and answers.  He seemed to be actively listening and empathetic.

In what areas can the practitioner improve?

The practitioner needs to use more open-ended questions and commands to increase the flow of information. The therapist can also use more continuation techniques such as ‘go on’ and ‘really’ to keep the flow during the session. Sadock, Sadock, & Ruiz, (2014), noted that the goal of the interview is for the client to tell his story. Open-ended questions cannot be answered with a simple “yes” or “no” because they identify an area but provide minimal structure on how to respond.

At this point in the clinical interview, do you have any compelling concerns? If so, what are they?

I had concerns about the following questions:

• “I think moms sometimes have ideas about things.”
• “What teenager really like talking to their mom.”

I feel like the practitioner validated the client’s negative feelings and generalized when he mentioned what teenager really likes talking to their mom.  In some instances, I felt the therapist reflected his own judgment especially in the two sentences above. The practitioner appeared to discount the complaint of the clients. The practitioner acknowledged the expression of emotions which made the client share more information. However, his opinions should have been offered judiciously and without leading or validating the patient into negative beliefs.

What would be your next question, and why

• Tell me more about your relationship with your mother?
• What do you think makes you disconnected from your mother?
• Tell me more about your family?
• What was your childhood like?

References

Carlat, D. J. (2017). The psychiatric interview. Philadelphia: Wolters Kluwer.

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

Sori, C. F., & Hecker, L. L. (2015). Ethical and Legal Considerations When Counselling Children and Families. Australian & New Zealand Journal of Family Therapy, 36(4), 450–464. https://doi-org.ezp.waldenulibrary.org/10.1002/anzf.1126

YMH Boston. (2013, May 22). Vignette 4 – Introduction to a mental health assessment [Video file]. Retrieved from https://www.youtube.com/watch?v=JCJOXQa9wcE