Mental Health Nurse Practitioner
Mental Health Nurse Practitioner
NURSE PRACTITIONER
“In Treatment” Assignment:
In Treatment is an American HBO drama, produced and developed by Rodrigo Garcia, about a psychotherapist,[1] 50-something Paul Weston, and his weekly sessions with patients. This program offers an exceptional insight into the life of a full time psychologist as he engages with his patients. For this assignment, you will be assigned one In Treatment patient to review. You will watch 3 episodes of therapy with this patient and complete the following questions.
1) Complete a patient intake. (15 points)
a. IDENTIFYING DATA/PRESENTING PROBLEM:(Description, Identification, Patient Statement of Presenting Problem)
i. Sophie (the patient) is a 16 y/o, gymnast since age 6.5, us junior champ age of 12, only child,
ii. Sophie had an accident, stated she needed opinion from psychologist d/t insurance company, other drivers insurance company has problem with patient injuries, insurance sent her to Social worker which patient did not like bc “she acted like she knew me” so mother sent her to see Dr. Paul Weston
iii. Sophie states she doesn’t remember happened, then states she was on bike then car hit her, she states that they said she “flew her bike right into the street” and she smiles/laughs
b. HISTORY OF PRESENTING PROBLEM:(Precipitating factors, treatment to date, etc.)
i. Happened at gas station near the gym where she trains,
ii. US nationals coming up, Sophie seems worried about this when she was talking, paul congratulated her and she said thank you but was looking “down”/kind of sad
iii. Sophie offers to show report and paul states “if you want me to” then patient becomes defensive stating that Paul thinks he already knows what it says,
iv. Sophie wants paul’s opionion without questions and only reading for which paul agrees then patient becomes defensive stating so you’re going to give me an opinion without any “shrink like questions”, patient begins to be tearful stating paul talked to her mom and he already knows everything that’s in that envelope (insert defense mechanism/delusion)
v. Sophie seems upset with Dr. Weston stating “I should have listened to my father, he called them a cult of crazies”
vi. (third episode) Sophie (the patient) opens up stating that Darlene (cy wife) came and told her that dana became too attached and that sophie should stay away for a while, Darlene then said “kids forget but grown-ups don’t” kind of hinting that Darlene knew what happened, Darlene gave sophie a gift from Wisconsin after that and left, that same night the accident happened, sophie took cy’s bike and went down a blind turn, a
white car almost hit her but the car moved away , she then admits she wanted to kill herself
c.Past Psychiatric History (First episode or symptoms, episode timeline; treatments)
i. Patient on motor bike 2 years ago of friends, she was bored so she pretended she knew how to drive it, she turned the handle a little and it flew, she took off and crashed into a car, old women present stated that Sophie tried to kill herself and Sophie was upset about that old women and wanted to tell her to shut up but couldn’t bc she couldn’t speak or move, sophie stated she wanted to “kill her” bc she was so angry,
ii. Pt states she has been “under pressure for years and she has never supported me” in regards to her mother stating all the other moms were at the gym and training camps visiting but sophie’s mom did not stating “what do you need this for”
iii. Sophie is drunk during this episode and tells a story about when sophie was young and parents fought, she would sleep over cy’s house, once they had to take her to the ER bc sophie was throwing up, feeling sick to her stomach; they never told her parents that and when paul asks why not sophie pauses and then randomly says she ruined their family, Sophie goes to Dr. westons bathroom and overdoses and gets admitted to inpatient psychiatric d/t this;
iv. sophie has a history of eating disorder, parental divorce also affecting her, states her father and coach Cy are the only one who loves her but as the episodes progress it’s revealed that her father barely calls her,
d. DEVELOPMENT/PERSONAL/FAMILY HISTORY:(Developmental mental milestones, sexual development, inc. sexual abuse, family background, cultural and religious background, patient’s perception of background, strengths and limitations)
i. (developmental milestones) Pt was in same grade as pauls daughter, patient knew paul was on PTA committee at Arlington elementary, paul
is surprised by this thinking sophie researched on him,
ii. (family background)Patient presents with some problems with mother during first episode
iii. (family background)Pt states that mother thinks that because of all this “competition and perfectionism” that sophie wants to kill herself
iv. (family background)Pt states she calls “4-1-1” as a joke bc when she needs to talk to someone. her father has moved so many times in the past few years so she can never remember her dads phone number bc he changes it so many times so that’s why she calls 411 as a “running joke in the family”
v. (family background)Sophie states about her father that “he’s the only person in this world who truly loves me and the only one who believes the accident was not my fault”
vi. (family background)Father is a photographer for female model who does exhibitions at home (possible sexual development issues from sophie bc she seems women modeling for her father, so she wants this attention)
vii. (sexual abuse/development) Poss sexual abuse by “cy” her coach foreshadowed by a topless mermaid drawn by Cy on sophie’s cast and it was colored in by Cy’s daughter who sophie use to babysit
viii. (sexual abuse/development) sophie states at first she thought was imaginating but then sophie states she knew exactly what she was doing but doesn’t specify what with Cy, stating Cy was a gentlemen and that he loves her; then she states that Cy said that having sex was a line they would never cross; she reveals they would be sleeping in the same bed and the night before Darlene came home they had intercourse, sophie stated it “felt like nothing at all” stating it was like she was watching it happen on small black and white television (this defense mechanism of
derealization !
ix. Sophie is possibly staying at cy’s as she states she was cooking for them, helping Dana (cy’s dtr) with homework. She then states Dana would wake up screaming bc she couldn’t breathe, then pauses to realize she gave too much information and says Cy told her that.
x. Sophie likes Pauls wife a lot, wished paul’s wife could go with her to the gym to tell everyone the truth (instead of her own mother)
xi. (family background) Paretns of sophie don’t sit at same spot in meets, they sit separate, sophie states she looks “schizo” waiving to two different spots during her meets; she is visibly upset and angry during this
xii. (family background) sophies parents marriage ended during vacation to new York but officially when sophie got home from school and parents were in kitchen..they were both crying and sophie said to paul that they were babies and she was hungry not acknowledging the event; sophie states after that her mother was depressed so coach cy and wife Darlene would take sophie to practice and back
xiii. (sexual abuse/development) sophie gets drunk at party and has sex with male gymanist, she says she didn’t feel anything “as usual”, boy states that sophie has sex like someone who has been sexually abused
xiv. (sexual abuse/development) sophie states that her mother doesn’t want her to do gymnastics because her boobs will be small
2) Review the DSM-V and determine a diagnosis for this patient. (Make sure to provide specific examples to support diagnosis.) What are your differential diagnosis and why? (15 points)
a. Main diagnosis: Major depression (DSM-V: depressed mood but for sophie its more irratibaliity being she is a teen, loss of pleasure in her gymanist activities, signicant weight loss, feelings of guilt about ruining darlenes family, recurrent thoughts of death/suicidal ideation,
b. Differential diagnosis: anorexia nervosa (DSM-V: significant low body weight, states her trainer told all the girls that they cannot be fat,)
c. Sophie is projecting her inner thoughts that paul is a “liar” even though she is lying, that she is not “crazy”,
d. Sophie states other girls are “ana and mia” referring to anorexia and bulimia; Kate, pauls wife, was helping sophie change clothes noticing that sophie is “skin and bones”
e. Sophie reveals in 4th episode she would starve her self as a child, it would get so bad then just “go away”
f. Same with her pain she would push through it and it would let up, she states its like she did not have a body at all
3) Identify 2 therapeutic techniques utilized by Dr. Weston and provide support. Are the techniques effective? Provide support your answer (20 points)
a. Uses clarification
i. when sophie talks about failing Paul seeks to clarifiy what she said
ii. when sophie states her dad called her while she was in the ambulance he seeks to clarify how he knew that fast making a joke that her dad and sophie have telepathy
iii. when sophie states she got in another fight which was nothing new for her and her mom, paul seeks to clarify that something was different bc sophie left home this time
iv. when sophie was upset she didn’t get to go to camp paul clarifies that sophie doesn’t like karen, Audrey, shirely and that she can’t train anyways so why is it important for which Sophie states it is not important to her but then states she was looking forward to it.
b. Uses active listening
i. Paul pays attention to subtle remarks made by patient and is processing what she says such as “you have to make round window to the outside, then you’ll feel like your in a real ship” (real=possible defense mech or delusion)
ii. When sophie begins to speak a lot about certain topics paul stay silent and actively listens to what she has to say
iii. Paul used active listening skills from his first session by wanting to know why sophie stopped babysitting, sophie got defensive wondering if she told him that before or not, then she talks about how she babysat Dana (cy’s daughter) and how much she liked it while Cy’s wife was in
Wisconsin “processing cheese”, then she states that she “prepared” Dana for her mother to come back so she couldn’t babysit her anymore. Sophie then states “the whole like got mixed up in her head” for which Paul beings to reflect what sophie states about “living there” for which
sophie gets defensive. Paul continues to clarify what she meant for which sophie becomes restless. Paul remains quiet and sophie becomes angry and defensive asking “what the hell is going on here”
c. Uses silencei. when paul asks about mother patient becomes defensive so he stays quiet which makes the patient speak even more about her mother
ii. when paul asks sophie to tell him a little bit about herself she gets upset, he stays silent which makes sophie talk bout her past
iii. when sophie starts to insult paul, he remains quiet, making sophie talk even more about
iv. when sophie starts talking about the gym and the other gymnists, paul remains quiet and sophie begains to talk about about the other girls that they are ‘groupie sluts” trying to impress Cy, that the girls are bulimic/anorexic, stating that when the girls are about to fall they want Cy to
place his hand between their legs to catch them, (Paul remains silent this whole time for which sophie talks even more)
4) Describe the therapeutic interaction between Dr. Weston and the patient. Does the interaction between Dr. Weston and the patient present as ‘Classic” therapeutic interaction? (15 points)
a. The interaction between dr. Weston and the patient in the beginning episodes seems like something out of a TV drama. The patient is defensive, anxious, smiling/crying, while Weston is observing and trying to fit the role of a psychologist. He makes a TV line statement at the end of the session in regards to professionalism which draws sophie’s attention.
b. The setting in where it takes place is at Dr. westons house which is different from the usual outpatient setting at a clinic.
c. paul kind of plays a father figure in the sense that he has a daughter the same age; he knows that sophie has been sexually abused, he hugs
her and counsels her when she finally opens up about the suicide attempt
d. Patient states she feels sorry for books on top of the book shelf, paul asks why, she states “I don’t know they’re your f******* books buster”,
possibly a metaphor for patient being really good at gymanistics and being lonely being at the top,
e. Paul knows that sophies interaction with the social worker was more of the classic therapist client relationship and that sophie did not like that so he is taking a diff approach
f. Paul doesn’t probe into the suicidie specific questions that a therapist normally would do at signs of suicidality but instead stops bc sophie is upset
g. Paul also does not report the possibility of child abuse, in this case sexual abuse, but instead continues his sessions. This type of interaction is not correct and it is the responsibility of every healthcare professional to report child abuse even if its just a possibility.
h. Patient finds inhaler referencing that paul “could have died without it”. Paul reads report stating she could have died too for which patient states “Yeah that could have solved a lot of problems” for which patient states she was joking.
i. “I can’t treat somebody I don’t love” paul says this to sophie which is not appropriate for a therapist to say to a young girl, especially someone who was sexually abused
5) What style of therapy is Dr. Weston providing for the patient? What other types of therapy might be effective for patient with this diagnosis? (10 points)
a. “some ppl are afraid of theapy, they’re afraid that it might touch these wounds” paul telling sophie this
b. Asks about deep feelings that sophie might want to talk about
c. “your logic as some flaws sophie..you aren’t responsible for what happened in their marriage”; paul stops after this and changes the subject kind of going away from the therapeutic point of her perceieved thoughts and guilt/blame being wrong without delving into this or trying to change this
6) Provide a critique of Dr. Weston therapy style with patient. Does the patient seem to get better or worse? What would you do if this was your patient? (15 points)
a. Sophie really only gets a little better by the 4th episode but does begin to open up more to Dr. Weston about her past, her sexual abuse, her family relationships
7) Scholarly writing/ References Should follow format & citation standards of the APA Publication Manual (6th edition). (10 points)
