Mother and Daughter: A Cultural Tale
Mother and Daughter: A Cultural Tale
- Review psychotherapy genograms.
- Download the Comprehensive Psychiatric Evaluation Note Template and review the requirements of the documentation. There is also an exemplar provided with detailed guidance and examples.
- View the Mother and Daughter: A Cultural Tale video in the Learning Resources and consider how you might assess the family in the case study.
Document the following for the family in the video, using the Comprehensive Evaluation Note Template:
- Chief complaint
- History of present illness
- Past psychiatric history
- Substance use history
- Family psychiatric/substance use history
- Psychosocial history/Developmental history
- Medical history
- Review of systems (ROS)
- Physical assessment (if applicable)
- Mental status exam
- Differential diagnosis—Include a minimum of three differential diagnoses and include how you derived each diagnosis in accordance with DSM-5 diagnostic criteria
- Case formulation and treatment plan
- Include a psychotherapy genogram for the family
Note: For any item you are unable to address from the video, explain how you would gather this information and why it is important for diagnosis and treatment planning.
Submit your Assignment.
Mother and Daughter: A Cultural Tale VIDEO
Mother and Daughter: A Cultural Tale. . (2003).[Video/DVD] Masterswork Productions. https://video.alexanderstreet.com/watch/mother-and-daughter-a-cultural-tale
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IF YOU CANT OPEN ANY OF THE ABOVE LINK TO VIEW THE VIDEO, THEN THIS IS THE TRANSCRIPT…..
TRANSCRIPT OF VIDEO FILE:
A MOTHER and A DAUGHTER:
00:00:35: A CULTURAL TALE
AN INTERVIEW WITH
GONZALO BACIGALUPE, PhD
Andrews & Clark
GONZALO BACIGALUPE When I’m asked to do a consultation, one of the first things I ask is, what will be the most benefit for the client and the therapist and in the case that you’re going to see I’m basically asked to have a reflecting team and what we did was first have an interview with the therapist and the family and ask them what they will find useful for the interview and basically to ask them about the history of the therapy and the history of what are the kinds of things that they have been working on. I ask the reflecting team to come in and I instructed them to think of themselves as so let the god mothers of the therapist, who in a way, put them, himself, or in this case herself at risk in front of her peers and another people. So, I wanted them, the reflecting team to address the therapeutic system as a whole not just to address the family, I wanted them to talk also about the therapist and to be protective of them. I also ask the reflecting team not to be too much of clinician, but to really react on a more personal level around the family. I sometimes reflected on what they were saying to clarify or to expand the idea or how I understood it to give voice to other possibilities, but respecting the personal peace, and then, I ask I ask the family to come back to, in a classical way, to respond to those comments what strike them. In the case that we watch, it seems that the family was dealing with sort of like two forms of trauma and/or three forms of trauma; one is, history of battering the domestic violence, child sexual abuse, a history of immigration that in some ways we lay it to that trauma getting away from it and basically the mother of five children deciding that they need to move out of the home, but in the process leaving one behind who is later on sexually, I mean, raped by the father. And then at the present moment mother dealing with a fairly traumatic illness that have her, very disable, unable to walk and to work. So, it’s sort of like the interview trying to address this different forms of trauma and the way in which the young adults are trying to make sense of their bicultural life and how the whole family is trying to make sense of being bicultural and being immigrants. The session doesn’t end with a need or incredible intervention of my part because I feel that this is the part of the therapist to try to decide, this is the family that’s been working this therapist for year and half. Therefore, they have a relationship I feel that I need to respect and so those are the basic intercomments. So tell me how is it that you came out with the idea of having this interview with me?
SANDI Okay. I’m going to go back when Patti came in for the first time. She came in because they were chaos at her household.
Sandi – their therapist
SANDI She came to this country twelve years ago with her four children and one was left behind, her daughter who was 10 years old at that time, eight years old at that time, was left behind. Just two years back, finally they were able to get her visa and she brought her to United States. So ever since she came here chaos was created inside the household.
GONZALO BACIGALUPE So I’m clear, Sharleen you are?
SHARLEEN Her daughter.
GONZALO BACIGALUPE Her daughter. And how old are you?
SHARLEEN I’m 23.
GONZALO BACIGALUPE 23, and how old are your siblings?
GONZALO BACIGALUPE And that’s sister or brother?
SARLEEN And then 21-year old sister and 18-year old brother and a 15-year old brother.
GONZALO BACIGALUPE Okay, and which one is the one that stayed there.
GONZALO BACIGALUPE 21. Okay. All right. Okay. Go ahead, sorry.
SANDI And I met with the entire family for two couple of sessions and she really interested and wanted to be in therapy 21, so.
GONZALO BACIGALUPE What’s her name?
Shireen – the 21 year old sister
emigrated from Iran 2 years ago
GONZALO BACIGALUPE Okay.
SANDI She just felt that she needed the money more than coming to therapy and she refused the entire time and mom tried to she ask her, if she doesn’t feel comfortable with me. She said she has had all appointments with other therapists at this clinic, still she refused to come in, but they kept on seeing Patti and the oldest daughter Sheela for about a year and a half now. Ever since then, we started working on the chaos in the household, what is it that creating chaos and I found out that Patti lives with traditional ways of living, their daughters are trying to detach herself from Patti and grow on their own and find their own individuality. So would ask where they have been working on and every since then she had two surgeries.
Patti had surgery on both feet.
SANDI Every thing is started.
GONZALO BACIGALUPE Who had two surgeries?
SANDI Patti had two surgeries on her feet.
Surgery failed – she is disabled.
SANDI And that created more tension, anxiety in the family.
She is in constant pain.
SANDI So — and I have been seeing her after her surgery and she has been referred to a psychiatrist for medication because a lot of time she feels hopeless, helpless, she feels her children are out of control, she can’t be in charge, they no need her anymore. So those are the major.
GONZALO BACIGALUPE If you were to describe an accomplishment and you have accomplishment with the therapists during this time. Is there something that you will say, it’s an important accomplishment?
SANDI Awareness of the difference between individualist ways of living and collectivistic ways of living and awareness that how they to respect and understand the children are growing in this country and they are going to try to detach themselves from Patti to be able to grow on their own.
GONZALO BACIGALUPE What has been for you this work with Sandi?
PATTI She helped me to understand the kids grow up and left the house and they have been not to depend on them so many times and try to live my life alone and then to take care of my things, my problem in the life and respect them and give them their freedom.
GONZALO BACIGALUPE Do you have a sense that that is sort word that has been accomplished that is more to be done.
PATTI, I think I need more to be done, I’m not done. No.
GONZALO BACIGALUPE, do you have of sense of what is that you would like to do?
PATTI Yeah, I’d like to learn to lead my life alone and depend on the kids a lot because in our custom when the parents get old and especially when they are in my situation they can’t walk or take care of theirself, the kids are always there for parents, but over here no, they have their own life. And I expect them to be there all of the time for me and they can’t, matter of fact, I had a big argument with her last night about that, I had a very bad back for few days I was done and last night, I called her and I said come and spend a night with me and she said no, I can’t. I said, you should and you have to and we got into a big argument.
GONZALO BACIGALUPE So, you are on your own right now, you’re living in your own and each of the kids have their own place or?
PATTI Three of them, two of the boys lived with me 18 and 15 years old, but the 15 years old was with her for three four days and I was with 18 years old a lot. I feel like they doesn’t do enough for me.
SHARLEEN, she makes her own plans for me, she expects me to like to go with her and spend time with her because she is bored. I have too much to do, I can’t unwind your boredness, find something else to do, but I have plans, I’m 24 and my world around me is happening and I need to be there, I accomplish things. I can’t sit down and like chitchat for a whole day.
PATTI And I feel I’m depressed I cannot move, I need them to come and visit me, spend a night with me.
SHARLEEN, I spend, I — out of the seven days, I saw her for six days, I make sure, I saw her for six days out of that week. I spent a day with a friend and I got some stuff done and she felt like I owe her something because I didn’t spend that time with her. And she did a nice job raising us, she was a wonderful mother, we all suffered through the good and the bad in the family like every family does, but we have all grown up, we can’t stay in the nest forever. I’m trying to experience life and my own good or bad, whether you approve it or not, it’s my life.
GONZALO BACIGALUPE Sharleen, is this something that you have had a discussion, the three of you, I mean this particular or this is not like?
SHARLEEN I think, I have mentioned to her, but she takes it personal, she doesn’t hear me out.
GONZALO BACIGALUPE Is this something that you have had conversations with the family?
SANDI Over and over, yes. Especially with the oldest daughter Sheela, she also, being the oldest, she feels that she has been the parentified child all her life, she has played a role of a man for — in her mother’s life and then the entire, I’ve seen her for about four times right, four, five times and she used to cry the entire time in the session.
GONZALO BACIGALUPE And I realize that you’re being very touched by this, I mean this is not something that.
SHARLEEN Yeah, it’s something that I strive so hard to accomplish and as soon as I feel like I got her on the right step, there she goes falling depart again asking for like, I give her what I can and she keeps on asking for more and more and that’s not how my life works.
GONZALO BACIGALUPE What do you right now? Are you working, studying?
SHARLEEN Yeah, I work and I’m trying to get my license. I’m trying to get accomplish things from now.
GONZALO BACIGALUPE What kind of work are you are doing right now?
SHARLEEN I just — I find promotional jobs and then, I’m trying to get my real estate license.
GONZALO BACIGALUPE And your sister?
GONZALO BACIGALUPE Sheela, is she also on her own?
GONZALO BACIGALUPE She is also working, studying? And the 18-year old, what is he doing?
PATTI He is a student.
GONZALO BACIGALUPE In high school?
GONZALO BACIGALUPE So, he is finishing high school right now?
PATTI Yes, this year.
GONZALO BACIGALUPE And is he talking also about leaving home after finishing the high school or what are his plans?
SHARLEEN He is not sure yet, depends on how the family situation is going, you know, everybody looks for happiness and peace of mind, depends like how he feels around the home.
GONZALO BACIGALUPE How about the 15-year old?
PATTI I have lots of problems with him, I don’t get long with him at all.
SHARLEEN She has no patience. And she takes it out on other people.
PATTI Because I can’t do anything, I walk fewer step and that’s it, I have a horrible pain after fewer step. And I have to sit and wait for them to come and give me a glass of water.
SHARLEEN Well, the thing is I want her not to wait for us, I want her to be on her own, I want her to learn how to like, you know there is a — you know superman lost his both feet and he sits on a wheel chair, but he is still going on with life.
PATTI But Superman has money, somebody take care of him all of the time.
SHARLEEN You have to learn how to ease your own mind and not depend on other people. She is forty years old, if she was 60, poor dying lady, I would be more sympathetic, just 40 years old, there is much more for her to experience. It’s not time for her to start depending on her children yet. We’re only in our 20s, let me live life, let me experience and do what you can, while you can. Give it your best.
GONZALO BACIGALUPE Sharleen, how is that you decided to come today, I mean what’s it?
SHARLEEN Because I was with her last week and they asked me to, they invited me to, so I thought maybe you would like help as much as this is helping you.
GONZALO BACIGALUPE Do you have a sense that you are sort of being representative of the other of your siblings that you are coming as a representative for all of them in some way?
SHARLEEN We are all trying to get her to be more positive and feel like do a little step at a day, but try your best to be better, to do a better in life. Every time I try to push her to be more independent and not as much like do that all stuff with her that she could do on her own, she keeps like she has a broken wing that she wants to buoy on us, after a while, it gets heavy. You just want it off because I want to breathe and I want to experience my life. I cannot live like a 20-year old from Iran. I have different things to experience than to sit at home. And the thing is like I don’t feel like I can accomplish with her when I’m at home because she is either watching TV or on the phone, which is just like sad people around and I can’t hang out like that.
GONZALO BACIGALUPE Besides the — your five kids and yourself, is there anybody else in the family here who immigrated with you guys or –?
PATTI I have a cousin, but they live LA and I don’t even talk to them.
GONZALO BACIGALUPE And so, in a way, when you need something, basically the only thing that you feel like you can go for your kids? When you — we’re talking about chaos, there have been — there were some chaos about a year and half ago when we start through the work and can you tell me little bit about what the chaos was about or what — how you define that?
SANDI Okay. I just want to mention something about before her surgery Patti has been a very independent women as far as working hard, single mother, raising all her children and they are all proud of her in many ways. When they came she did not have the health problem as far as the pain in her feet, constant pain and feeling hopeless and helpless. They came for a different reason was for Shireen, because Shireen came form Iran and two weeks everything was wonderful, they all re-united, they enjoyed, celebrated for two weeks, and then, she started telling him about the stories that her father abused her sexually, physically and she was abandoned in their house. So, that’s where the explosion, the chaos started. Before that —
GONZALO BACIGALUPE When you say that the chaos started, what started to happen?
SANDI They were fighting, constant fighting, screaming, yelling and cursing each other. Before that, my understanding was that kind of was a very peaceful way of living, am I correct in this?
GONZALO BACIGALUPE Okay. All right, so the tension has really sky rocketed after Sheela came back, I mean, two weeks after one, and then, he came out of that — there’s been this –?
PATTI As she came back, she was blaming me, why did you left me back home with my dad there, he did all of those things to me. And my husband used to tell her, you was a rotten fruit and she didn’t take you, you are a rotten one. She took the good ones and left you behind for me. And she was blaming me for everything.
GONZALO BACIGALUPE When you left, you had separated from your husband?
PATTI No, we were living together my daughter had a medical problem, Sheela and matter of fact, her, and they give me a medical visa to come here and Sheela and Sharleen born here many years ago. And when I went to get a Visa, they told me two of them are American citizen, you have to take them, we cannot say no. And my boys were four years old then 18 months old and Shireen was eight and they said, they decide Shireen should be stayed home and make it sure I’ll will be go back. But after I came here, my daughter didn’t have any problem any more and they were find and I used to stay here and I decided to live here. And my husband was keep telling me don’t come, don’t come, stay there, I will come some day and he never sent me any money, he never did anything for us at all except sending the letter 10 pages every single day, what to do, how to leave and how to raise the kids and I throw them all in the trash because I didn’t had a time to read them and I didn’t had time to practice anything he said and I ignored everything until like six, seven years later, he just wrote a letter, I want you to be back home, you are my wife, I order you to back home and I said, forget about you, I have my life here. And who wants to go back to that life. And I was thrown all of the time to bring Shireen and I couldn’t until three years ago. Finally, she came and for couple of days, weeks everything was fine until she started talking about every problem she had back home and for any little mistakes she made, my husband used to beat her up and keep her outside the house for all night and many, many things, the things he used to do to me. And I know what she talking about and what she had to go through, but I couldn’t do anything about it. I didn’t have the choice. When I came here few week after, few months after I was here I called my dad and I said, I’m worried about Shireen, I afraid to beat her and I’m not there to protect them because I was all this over to protect the kids. Each time he wants to beat them, I was right ahead of them and say, beat me, don’t touch my kids, do whatever you want with me. And my dad said you should imagine your house was in the fire, you took four of them off the fire, you left one behind, leave her behind and take care of those four you have and I thought about it, I thought, he is very right, absolutely right, I should take care of the four I have over here. Why should I go back there. He would be — make everybody miserable. I didn’t have a very good life but like she said, we all worked together and take care of each other and like I was out all of the time and like Sheela said, she was father of the kid, take care of the kids, take care of the bank account, his groceries, everything. And I used to be a care giver and save it all this and Sheela and Sharleen would stay home and take care of the kids, two younger brother and each other. And everything was okay until Shireen came. And then, after few months, for a couple of years, we had a problem until, thanks god, last May she got married with somebody behind our back.
GONZALO BACIGALUPE Who got married?
PATTI Shireen, we were on the camping three when she ran away with one of my friend’s son and got married and she moved out the house and my house is so quiet and I enjoy the life so much except I get so depressed because I feel hopeless and I have so much pain and they can’t do anything about my pain, I’m always in pain.
GONZALO BACIGALUPE As you must have seen, when — do you work on how they make sense of what happen to Shireen, I mean, in Iran during the time that she was alone, was that workout with the whole family, they were some sort of a conversation in therapy?
SANDI Yes, I met, as I remember, I met with all of them and they expressed their feelings and shouting, yelling, everything was going on in our session. And they were expressing, Shireen was constantly blaming the mother for all her pain and what happened to her to lead on and a mother tried to explain her situation, the sisters also, brothers also. So, we had few sessions like that.
GONZALO BACIGALUPE What was your sense of how it can — that there were some sort a resolution around that that people were able to make sense that Patti and the kids were able to make sense of this or?
SANDI I was hoping for that, that was my really aim to discover, explore their meanings of the situation and.
PATTI They got in fight, we couldn’t keep coming back, I couldn’t make them to go back as a family.
GONZALO BACIGALUPE Is it still something that is very hard to talk about or not?
PATTI About the rape you mean?
GONZALO BACIGALUPE Yeah?
PATTI What do you think?
SHARLEEN Well, I’m not very worried about, I mean, it’s affecting her life and I feel sorry for her, but I try not to think about it.
GONZALO BACIGALUPE And do you have the sense that that’s what anybody else in the family tries to do that tries hard so they doesn’t affect?
SHARLEEN Because we already did our crying over it and I’m over it, I’m ready to move on about it.
PATTI It’s like when somebody die, you grieve for it. When I heard about it, I was crying and crying and crying for months and months, and then later on, it’s something you can’t do any thing about this, something happened, what am I going to do about it. I tried to take her to counseling, I take her to Iranian psychologist, 200 dollars an hour. And she would then go back, then what can I do. And I think I’m over with it, I feel sorry for her, but what can I do. My older son doesn’t want to talk to this, his dad, nobody wants to contact him or have any relationship or any thing to
GONZALO BACIGALUPE Has he acknowledged that he did rape her?
PATTI I told him once, and he will start cursing at me and I hang up. I said, I pay a dollar fifty a minute, I don’t want to hear your cursing. I want to see what’s going on, what happened and you tell me if it happened or not and will start cursing and I hang up. And after that, I never called back, and he is remarried, he married to Iris after Shireen came, during the three years, he got married twice and he has moved on with his life.
GONZALO BACIGALUPE Is there any, I mean, is there a way in which you think, I mean you, Sharleen and maybe some of your siblings, but just from your perspective, is there where you think about how the relationship with your mom should be, is it — do you have a dream for how?
SHARLEEN Yeah, I just wanted her to be more peaceful. I want her to lower her expectations and to accept a lot of things about life.
GONZALO BACIGALUPE What do you mean lower expectations, what?
SHARLEEN Not to expect so much from people, not to — I think what she does is, she thinks of an idea and she reacts on it so so quick without she calming herself down before she like takes the reaction.
GONZALO BACIGALUPE Do you have a sense that your mom thinks that you can do more than what you can actually do?
SHARLEEN I have a sense that she is holding me back from doing all that I could be doing and as soon as I could get excited about her, every time I give her little bit of hope, there she goes back expecting more, and then, getting angry at. She has some thoughts then she is so hang up that these thoughts are like so true and she gets angry about them and she hold on to them, then she accuses people and all they are her thoughts in her mind. And I just ask her to leave them alone, let people be and everything is going to — just then it’s going to take its course.
GONZALO BACIGALUPE Am I trying to tell you, if you were to think about how your ambition, how you see it in the future, the relation how do you see it? I mean, if you were to move in a way the direction that you want it to move, how many times do you see yourself beside in her or interacting with her?
SHARLEEN I speak to her every day, I mean almost everyday.
GONZALO BACIGALUPE But again, I’m asking you more about —
SHARLEEN Like in the future, yeah, I just want her to like be more calm about like life so that I could like through her better. So that when I do spend time with her that I could enjoy it better instead of her frightening my other siblings or telling me about how so and so, this and that and this and that. I just want her to be more calm so we could just enjoy the moment when we hang out, rather than like.
GONZALO BACIGALUPE What kinds of things do you enjoy with her in the moment?
SHARLEEN I try to tell her about my ideas, how she is like be more relaxed and not — you know same things.
GONZALO BACIGALUPE Patti, how do you ambition the relationship with your daughter?
PATTI I saw her on Sunday, Sunday night and Sunday night, I went to visit my older daughter and she was aware that I took the dinner for them. And after I laid down fully at my daughter, older daughter house, I couldn’t get up, they pulled me and took me to the car and I came home. I didn’t see her until yesterday afternoon and I said, I have been done with my bag. I just want them to spend time with me. I’m lonely, I get depressed when I’m lonely. If she had a job, if she was working like the other people, I would understand she is working everyday like my older daughter, she go to her school, she work, I understand she doesn’t have a time, but I know she has time and I expect her to come and spend the time. And I said, I gave you whatever you want, whatever I have in the house like furniture, this and that, anything she said, mom can I have this? Sure, honey, doesn’t matter you or me, you can have it. And when I’m like that with you, I expect you to do something for me too.
GONZALO BACIGALUPE Patti, I understand how also you are feeling upset about this, about and I know that the question I’m asking is hard, I mean, how do ambition the relationship with Sharleen? What will you like to happen in the future?
PATTI Between me and her? I want her to just spend time with me whenever she can.
GONZALO BACIGALUPE What kind of time for instance would you like to –?
00:29:45 PATTI She come and stay at my house because she knows I cannot live with two boys and go to her house. She most of the time ask me to come and stay at my house, but when I go to her house and I spend over there, I’m worried about 18 years old I have at home.
GONZALO BACIGALUPE And do you have a sense of how many times, how many nights that you would like her to spend with you in your home?
PATTI Once a week is good if she come and stay the day or night, once a week with me is fine, but when she come like one hour, half hour, she is for example, going to go see so and so to keep a board work, she will stop at my house to have a drink the water or say, hi mother, how are you?
SHARLEEN Two, three hours?
PATTI That’s not a visit for me, I wanted to come with me and spend the time with me and stay with me that day.
SHARLEEN When I go over there, she is either on the phone or she is watching TV, I’m very, very uncomfortable in her house like to where I cannot stand sitting down because she has two dogs around and I don’t like those things. I don’t like the hair on my body. When I touch an animal, I wash my hands before I eat. She has two dogs, there is dog here on the couch, dog here on the floor, dog here on the chairs, there is dogs all around. I don’t want to eat anything because the dishes smell like dogs, I’m not comfortable. I don’t enjoy that, it’s not pleasant to me. I could only do it so much at a time. I express that to her, you have dogs, I can’t eat either your dishes. That’s my culture, that’s how I was brought up and I thought that’s how she was brought up. So, she surprises me when she does these things, she makes the family unhappy because nobody wants to see dogs, it smells like dogs in her house.
PATTI How come you don’t do the other things, you grow up and have a cold chill like, that’s just the only thing you know.
SHARLEEN I don’t — I cannot stand it, I cannot stand it.
PATTI And they give me so much happiness, they make me so happy, I love them so much.
SHARLEEN I don’t like it.
PATTI And I never ever going to get rid of them.
SHARLEEN I don’t like it, don’t ask me to sleep in the pillow, it’s that the dogs stinks.
PATTI Actually, you know we have a guest room, the dogs doesn’t in that room.
SHARLEEN I cannot sleep in motels, I cannot use other people’s bed, I cannot sleep with dogs, I cannot do these things.
PATTI You know that bed brand new and you know the sheets and everything brand new in the guest room and you know that that door is closed.
SHARLEEN I’m not enjoying it, I cannot eat breakfast, when I’m thirsty I can’t drink water there.
GONZALO BACIGALUPE Let me ask you, is this the kind of sometimes the — where the discussions go?
GONZALO BACIGA And if I were to let you go over the discussion where will it end, one of you will leave the room or –?
SHALEEN I will start screaming.
PATTI Screaming, yeah.
SHARLEEN And disrespecting and calling names.
PATTI I do.
SHARLEEN At this stage, I don’t —
GONZALO BACIGALUPE And you would be like, I don’t want to see you, I don’t want to talk to you anymore.
SHARLEEN I’m trying to become a woman, I’m trying to became a lady. And when I go to her house, she treats me disrespectfully like that about her dogs, she would curse me out and I just feel, oh, what a mother.
00:32:40 GONZALO BACIGALUPE Would you say both of you that you would like that not to happen that you will not get into this.
PATTI Of course I love them.
GONZALO BACIGALUPE Do you sometimes dream with, been able to relate to each other without having to get into this.
SHARLEEN Of course, I do.
PATTI I feel even we argue, we still love each other and I feel like, they are my kids, they will be still here for me if I need them really. And they have been until sometimes lately.
SHARLEEN I just want her to appreciate and not to expect and expect just like take what people give you and just be happy.
GONZALO BACIGALUPE We’re going to stop a little bit now.
Reflecting Team Enters
ISAAC I’m Isaac and I really resonated with Sharleen. I come from, well my parents emigrated here.
GONZALO BACIGALUPE Where your parents came from?
ISAAC Korea, and I was born in the States, but there are still this cultural tension that we experienced within our family. And so when she was talking about the difference of cultures and who she is and there was a little bit of disparity between her Iranian culture and the American cultures in her life and I experienced that in my life too. So, I really understood that and I thought, you know what? I’m not the only one that went through that. And if I’m not the only one then she is not the only one either, so something that I guess happens in a culture of people when they immigrate into another country.
GONZALO BACIGALUPE How old were you when you immigrated?
ISAAC I was born here.
GONZALO BACIGALUPE You were born here, but still —
ISAAC My parents, my parents moved here. When they were in their mid-20s, they moved here. And then I was born and shortly after they moved here. And so there was a been influence there.
GONZALO BACIGALUPE All right, cool.
ROBERTA My name is Roberta and these things really struck out with me because I have seen Patti before. I have been on the reflecting team. And I’m amazed at the difference in her, how much younger she looks and more vibrant than the last month I had seen her. So, I was very impressed by her change. Another thing that just really struck out from me was when Sharleen was talking about what she didn’t want to do, and then, Patti talked about when her husband had sent her the letters and said, come home and Patti didn’t want to go home and it was almost like it was the same conversation, only held with different people. And I thought that was rather interesting that they are both having the same things happen in their life at different times, but they both wanted their independence. And I saw that realistic out from me, so that was very interesting.
GONZALO BACIGALUPE Yeah, it’s interesting, I was — I don’t know if it’s the same you are saying, but how can you have your independence, but at the same time, still stay connected? It’s a hard one.
ROBERTA And they are fighting to stay connected.
DOROTHY First of all, I’m really impressed with Sandi, the therapist and working with this family and having the care and the love that it concerns between all of them, including Sandi as a therapist. And I really relate it to Patti because I have six children and I watched them one leave one at a time and so I know what that feels like.
GONZALO BACIGALUPE What it feels like?
DOROTHY Well, it is — it feels like a tragedy really each time. There is always, there’s something to deal with because it’s a grieving, you are letting go. You are letting go and I really relate it to her on that level, completely, but I didn’t have the kind of real tragedies to deal with that Patti has had to deal with, in addition to this letting go, okay. She has had the, well, the disability to deal with in the pain, the constant pain that she deals with and also then the tragedy in her daughter’s life and what must come up for a mother in dealing with that. I mean, unavoidable in the situation, of course, but still she was dealing with that. At the same time, with all of this other emotional stuff that I know about. So, I just have a lot of respect for her and I noticed that she has done a good job with her children. How wise Sharleen is for a age, very wise, so.
GONZALO BACIGALUPE In a way, Roberta?
GONZALO BACIGALUPE Dorothy, in a way it is if it’s Sharleen’s need for independence is in a way due to her mom’s wanting her to be independent to and sort of like I mean she has to get it from somewhere right?
GONZALO BACIGALUPE Yeah.
AMBER Yeah that was a kind of a question I had. Well, what were Patti’s dreams for her children in making this enormous transition from Iran, right.
GONZALO BACIGALUPE Yeah.
AMBER To the States, this huge transition, I mean, there must have been a dream, some purpose that was bringing her over here, and I was really curious what her thoughts back, I guess, 20 years ago or something like that. And I loved Sharleen’s metaphor of the birds, the wings feeling, really weighing her down right now.
GONZALO BACIGALUPE And at the same the time, the wings are supposed to be as somewhat you fly on. Yeah.
AMBER Yeah. And so at that kind tied into my thoughts about what were Patti’s dreams for her — duckling in a way. I do not just kind of rambling thoughts about duckling is calling around and the infant their mom and their mind they follow her around forever even when they grow up, but they do eventually gained some distance more than they had.
GONZALO BACIGALUPE Maybe one comment, so maybe you want to say something else, I mean, maybe there is a couple of burning comments that people want to —
ISAAC I know the family really loves each other. Even if they argue, you see that there is a sense of care and compassion there for each other and I don’t think that.
GONZALO BACIGALUPE And in that sense, it must be very frustrating to get into this stuff, it’s like.
ISAAC Oh yeah, absolutely.
AMBER Yeah Patti made that comment. Even when we are fighting, I know we love each other.
ISAAC I said they’re going, you know, that’s exactly right, when she said that and even though, Sharleen is — it seems like it’s little bit tough love going on, on behalf — from Sharleen’s part of she representing all the kids, from kids towards their mom, and saying, mom, they love you, but we want you to be able to function on your own and I don’t know how that kind of fits in with everybody.
GONZALO BACIGALUPE Yeah. I was wondering what it is for a kid even if it’s an adult, I mean and clearly these are — kids were becoming adults I mean, Sharleen put it very well. But it must be really hard to see your mom becoming a little bit, you know sometimes like a kid to, I mean, that they need to take care of so soon.
ROBERTA And she made that comment if she was older it would be different, but she is younger. And I don’t think they expected, I imagine she is torn with wanting to live her own life and wanting to take care of her mom, I’m sure she is struggling deeply.
GONZALO BACIGALUPE Any of you thinking as a therapist, putting yourself in Sandi’s shoes and anything that you may think that Sandi is having to deal with or some dilemma that she may be struggling with?
ROBERTA What I felt for Sandi, because I think this must be very difficult for her also to, because the families seems even though they have said they have grown and they have made changes that they are almost stuck on that and I imagine Sandi is probably having a hard time getting over that stuckness, and so that’s what I see Sandi probably struggling with. It’s just being stuck and where do I go from here, where do I take the family from here?
GONZALO BACIGALUPE I was wondering, I mean, and the reason I guess I had a self-interest in asking because I was wondering and wanted to check with you guys, I mean, since she’s also from Iran I mean, people might think that she is more of an expert on this family. And of course, there are things that have to do with being from Iran. Also, the things that probably have to do with being an immigrant, but also there is some tragic things that have happened in this family and that you know, so I wonder how she at sometimes might feel like not necessary knowing what to do and while at the same time, feeling very well connected with this family.
AMBER Oh I think she is.
ROBERTA She shows she’s well connected with that.
DOROTHY Oh yeah. And it must be very frustrating because how do you improve the quality of life for Patti, especially for the family in general, I mean, it must be very frustrating. I mean, what concrete steps do to take.
GONZALO BACIGALUPE Okay. Alright. Thank you.
Family & Sandi Return
GONZALO BACIGALUPE I generally ask after this, we call this is a reflecting team, if you had any reactions, any thoughts or — and you don’t need to address everything that was — I mean, anything that strike you?
SANDI For me, I really felt that they hit — they touched the right sensitive part as far as being stuck, I’m always thinking okay, what else, what can I do to really — what can I, I come with ideas of goal setting, achieving goals, and trying to figure out what else can I do, so the family can —
GONZALO BACIGALUPE Move forward.
SANDI Move forward.
GONZALO BACIGALUPE Patti, did you, of what, all what you heard, there was something that struck you something new or interesting or –?
PATTI Nothing, they just talk about discipline on this — think you were asking me about Shireen, how do I feel and I told you I have been grieved and it’s over, but I was thinking about, it’s always in my head. I don’t think I never going to forget it. It’s always in my head and sometimes I feel like, maybe if I was there, it wouldn’t happen and then I think about rest of them, what could have happened to the rest of them, maybe if I’d take them all, what would be happened to all of them. So, I don’t know.
GONZALO BACIGALUPE Do you move back and forth between that. Sharleen how about you, anything that strike you as?
SHARLEEN Oh pretty much everything everybody said was really interesting to hear about.
GONZALO BACIGALUPE Anything in particular that?
SHARLEEN I don’t think so.
GONZALO BACIGALUPE You don’t think so. Is there a movement and this is something that it’s like you have been working for a year and a half, you have been going through some very difficult stuff. Do you see yourselves and maybe you can imagine your siblings thinking about this. Having other, so like very difficult conversations therapy, I mean do you see yourselves having to deal with tough issues? Or will you say that this is the worst so to speak?
PATTI This is the worst. Just argue with them because I love them and I don’t want to argue with them. I want them to have a good life and get married and move on with their life and I see them happy in their life.
SHARLEEN And sometimes she wants to choose our happiness for us, and that’s not going to work out here.
GONZALO BACIGALUPE Tell me how that works, I mean, you guys are —
SHARLEEN She wants to like choose our friends or choose where I hang out or boyfriends or husbands.
GONZALO BACIGALUPE And she probably gave up already.
00:45:55 SHARLEEN No, no. That’s the thing.
GONZALO BACIGALUPE You really think that’s not the —
SHARLEEN No, that’s the thing, she hasn’t given up.
PATTI I was supposed to.
GONZALO BACIGALUPE She hasn’t given up?
PATTI I was 14 when my parents chose my husband for me and I got married. And he was a nightmare, he was a man from hell, I think, sometimes. But I hate to say that especially in front of the boys, but he was. But the thing is sometimes I think is not fair what happened to me, I do it to them, but sometimes, I feel like if I don’t get involved they don’t know what to do.
SHARLEEN She doesn’t leave things alone like if the water is all calm, she has to drop a rock. She doesn’t let things be.
PATTI I see there are good looking guys, I keep telling them, look at him, he is cute, look at him, get close to him or something like that, I want them to get married.
GONZALO BACIGALUPE But in a way you gave up the notion that you’re going to have to choose.
PATTI Not they choose, yes.
GONZALO BACIGALUPE A boy I mean, for them?
PATTI Choose, yes, I don’t want to choose her husband.
SHARLEEN Sometimes I feel like she suffocates us with her opinions and her thoughts and her beliefs.
GONZALO BACIGALUPE Tell me about an opinion lately.
SHARLEEN I mean, they are nice, but.
GONZALO BACIGALUPE Some of the opinion that really —
SHARLEEN They make sense, but they make sense to you, not everybody has to go along with what you thing is the best way to do things. And she feels like, if you want to be a winner, you have to do it her way.
GONZALO BACIGALUPE Who is the more opinionated at home? I mean, she has a strong opinion, but who else?
SHARLEEN I think we all are that’s why we don’t get along. Everybody has an input.
GONZALO BACIGALUPE And do you have a strong opinion of how your mom should behave, do you see –?
SHARLEEN Yeah, I just wish she should be more calm, and what just she acts, so.
GONZALO BACIGALUPE Is there any space in this, which I mean, you did say that before that you have the dream that things were, that you were more calm, so that you could relate with her in a different level. Is there some space for her not be so calm?
SHARLEEN I mean, her house is what she creates for herself, to be calm or not be calm right.
PATTI Sharleen, and most of the time you guys come over there even with my bad fit dinner is ready, lunch is is ready.
PATTI We sit, talk and have fun, but sometimes like well, yesterday when I asked you to spend time with me you said, not it was an argument.
SHARLEEN I can’t, I had plans.
PATTI And most of the time they come over there and they have fun.
GONZALO BACIGALUPE But aren’t you —
PATTI It’s not always fun.
SHARLEEN Of course.
GONZALO BACIGALUPE Are you willing to allow for your kids to sometimes not to respond to your demand of what you want, I mean, is there sometimes some voice in you says, you know, maybe I know I will like that, but it doesn’t make sense again.
PATTI I do. You should have seen me before.
GONZALO BACIGALUPE Tell me about that.
PATTI No, honest, I used to want them to be there all of the time, but not now.
GONZALO BACIGALUPE I like your sense of humor actually.
PATTI Thank you. No, honest I used to be to be want them to be there all of the time.
GONZALO BACIGALUPE Ah, ha. So, now you want them sometimes, not all the time.
PATTI Like when they moved out, the first one moved out, I want her to call every.
GONZALO BACIGALUPE You were crazy.
PATTI Every hour, every hour, tell me what is going on, where is she going, what’s she doing and everything. Now, I changed a lot. Thanks to Sandi, I give them lots of freedom and space and I let them to choose what they should do and give them lots of freedom, don’t I?
GONZALO BACIGALUPE Have you been looking for boys for her.
SHARLEEN Nobody remind her too.
GONZALO BACIGALUPE Won’t you remind her to look for boys for you.
SHARLEEN Yeah, too much.
GONZALO BACIGALUPE So sometimes, I mean, in a way you’re seeing the changes, but sometimes you get as obnoxious about it.
SHARLEEN No, sometimes I just give up on her because I feel like, I don’t know how to get through her.
GONZALO BACIGALUPE Patti, let me switch a little a bit, because she said something that you probably guys can sort of like talk and addressing therapy. If you were not having this pain and you were not having this serious difficulty to walk, which is in a way sort of like a new member in the family, I mean, is a new situation I guess for you, it was not there. How — what would you be doing?
PATTI I was working first of all.
GONZALO BACIGALUPE What were you doing?
PATTI I was caregiver and I have told you. And —
GONZALO BACIGALUPE Oh I’m sorry.
PATTI I was a caregiver and I would be working 8, 12 hours a day and sometimes when I was off during the weekend I was shopping at the mall. When I go to a store I see, for example, meat are on sale I buy them all meats whatever it’s out there like, call her, I bought you meat, it’s awesome, it was all sometime I get it. Do things for them all.
SHARLEEN And that’s not right, because she is not letting us grow up and have responsibility, she wants to do things, these things for us and she —
PATTI Who said it is not right?
SHARLEEN She doesn’t understand.
PATTI Even if I don’t call and still you come and take it from the freezer.
SHARLEEN Mom, the thing I’m trying to — she cooks everyday as she delivers it to my sister’s food — house everyday. I tell her let her learn on her own, you do things for yourself, go for — don’t meat stuff, go for a massage, go for this and that, clean your room if you are bored. Learn how to read and write if you are bored, do something else, stop involving your plans so much around your children, find other hobbies, find other things to entertain your life with.
GONZALO BACIGALUPE What other things that she does for you or your siblings you will like her to continue doing?
SHARLEEN Be the same mother that she has always been, but just not expect so much because she gives, and then, she expects so much back in return, her expectations are too high.
GONZALO BACIGALUPE So you will like her to continue cooking and doing the things?
SHARLEEN Once in a while. Once in — don’t make it like, it’s a family ritual every week. Let it — let us — treat us like we have grown up and are out and doing our own life because that’s how it actually is. It’s just too much sometimes. I feel like, if it wasn’t because of my involvement with — so much of my energy involved with her, I would have probably take off to Europe for six months, work out there, do something, I would have a free mind to decide for myself, what to do for like a summer time.
GONZALO BACIGALUPE Do you have a sense that your mom may think that if she doesn’t do those things, that she would be thinking that she is sort of like neglecting with you guys?
SHARLEEN Yeah, she would feel like she has left us alone, that’s just her habit or how she grew up, her mom probably that these things.
GONZALO BACIGALUPE The time I will report her to child protector servants and doing the stuff.
SHARLEEN I don’t know about it, but she feels like she’s being the best mom.
GONZALO BACIGALUPE Are you ever thought about reporting her for, I mean for —
SANDI For great mom.
GONZALO BACIGALUPE For actually, no, for letting them be their — do their things.
SANDI On their own.
GONZALO BACIGALUPE Yeah. And have you thought about you could be reported, if you let them to be more independent or–?
PATTI No, not.
GONZALO BACIGALUPE I mean I never thought that in a way, I mean, negligence can be different.
PATTI I’d tell they love that.
GONZALO BACIGALUPE I was wondering if what it seems to bother you is not so much what she may do or what she may expect after she does it?
SHARLEEN I feel like I give her an inch and then she expects a mile. I give her like, I try to please her and please her let’s say, three days in a row, and she gets overexcited, then she thinks like it’s a shopping for everyday.
GONZALO BACIGALUPE What are you thinking Patti when you hear that? I mean, you are not getting angry at this point, you were so like maybe she has a point.
PATTI No, I will call her and I leave her home, but no.
SHARLEEN It’s really that’s how she things then, then I try to —
PATTI I swear to god, I will not call her.
SHARLEEN See, that’s —
PATTI I will not contact her and just leave her alone from now.
SHARLEEN She’s. I try to explain a point to her.
PATTI No that’s not the point.,
SHARLEEN Then she feels this way, I’m here to like, you know I feel.
PATTI I will give you the space as much as you want.
SHARLEEN That’s how she feels and I feel like sometimes she’s like so in her zoom box that she’s not willing to like let them down.
PATTI As a mother, how old your kids get then you see them like they are catching the fire, you want to grab them and not let them burn theirself.
GONZALO BACIGALUPE Your kids are going to be your kids.
SHARLEEN Yeah, but you can’t interfere.
PATTI It doesn’t matter how old they get, I want to go take them, especially because I had that abuser husband, I don’t want she marry somebody abuser.
GONZALO BACIGALUPE Let me — we are going to have to stop very soon and I was wondering Sandi, do you sometimes, in the sessions struggle with helping them to feed out how to negotiate these things.
SANDI I do constantly.
GONZALO BACIGALUPE And do you have a sense that that is sort of like that the struggle is that you know the man for mom to be more balanced, less the man they know or whatever, or controlling or intuitive or whatever the way the kids may see it, or the way Patti see it as, you know, this is the way I understand being a mother and this is the way I do things and this is when I want to take care of them. How each put the other one in sort of like a paradox, it’s like, love me, don’t love me kind of thing, you know.
SANDI Right, exactly.
GONZALO BACIGALUPE It’s care for me, but don’t care for me. It’s how to find that.
GONZALO BACIGALUPE That balance I guess.
SANDI Exactly. I have been focusing on more negotiation between them, and how they can compromise as far as what makes Patti happy and what makes the children happy. As for one big issue with Patti is the way they cloth also, the way they choose their clothing, that is another big issue. She is not happy with some of this stuff that you be talked about this before. So constantly I’m trying to balance between our way of living back home and our way of living over here, and by negotiation and compromise.
PATTI It’s mostly Shireen, the way she cloth, I don’t like it at all, I cannot even stand to look at her. I will have to steal it and throw it into trash can.
GONZALO BACIGALUPE Although, you know here you — it’s interesting because in a way here, you know in the stage you might seem like very conservative around it, but if you were to be Iran with all of the kids, you’ll be considered sort of like the revolutionary and almost hang you for allowing your kids to wear the clothing they are wearing right?
GONZALO BACIGALUPE And that’s that although, I don’t know how — although you are here, you saw you feel like you are there in some way, I mean, you carry your culture around is about you.
PATTI What do you suggest for me?
GONZALO BACIGALUPE What do I suggest for you? I don’t know.
PATTI Leave them alone.
GONZALO BACIGALUPE You cannot leave them alone. Right. But let me — I don’t think that you can leave them alone.
PATTI I’ll try it.
GONZALO BACIGALUPE But at the same time, I think that you need to add another something that you need to do, I mean, I don’t think that you can leave them.
SHARLEEN Yeah, find something to do.
GONZALO BACIGALUPE I don’t know.
SHARLEEN For real, find something to do.
GONZALO BACIGALUPE I don’t think that you can leave them alone. I think that you’re still going to be concerned about them. I mean it’s impossible for you, what impress me and this is something that coming to terms with what is happening to you and your body, it’s not an easy task, I mean, definitely it’s — it must be really, really, really hard, and how to have other people who can be a resource. I mean, you were having that conversation right now, how you can have other people who can be resourced to help you with that, I mean, that’s something that I think that should really be having conversation, the two of you.
GONZALO BACIGALUPE About what kinds of resources you can use besides you know, getting some help from your kids. I mean, because there are some things that your kids not able to do to help you with dealing with this pain and you know you were talking about your weight and how to heal this and on and on. I mean, this is sort of like a new adjustment. And before you were dealing something to happen in the past that came to visit during the present, you were happy a year and a half, you have always that sort of suddenly you were faced with this very traumatic event, series of events I, mean, what happened to you before you came here from what I understand was very traumatic. And sort of like now you are face something that is very traumatic. I mean, how do you deal with this excruciating pain, difficulty, I mean, how can you be able to walk in your own and having to — I mean, that’s — I find it very dramatic. It’s sort of like given up something, and you cannot just run away to another culture to run away from this pain. I mean, and clearly, you’re going to have to join something to be able to be aware, I mean, join, I don’t know exactly what, because that’s something that you probably know more about.
SANDI We’ve been exploring different options as far as resources. Patti came up and you came up with weight watchers idea. And she said, that’s some place I can join and it makes me feel good and I said, okay, then you are benefiting so many ways, your health, your weight and also the psychologically you are benefiting from that.
GONZALO BACIGALUPE Hope this was somehow helpful. And we don’t have more time. I’m really privileged for having you coming to the interview with someone you do not know anything about. I’m going to still thinking about this as I watch the video tape and I watch where we and I also would feel that there are things that maybe I didn’t ask, but that you would have asked and I would just share them with you. Alright, because I think that you guys said so much and shared so much with us. Alright. So, thank you.
SANDI Thank you.
GONZALO BACIGALUPE Thank you.
SANDI Thank you.
Family & Sandi Return
GONZALO BACIGALUPE I’m going to comment on some themes that had to with the interview per se with the family, the reflecting team for some conceptual ideas that I think that maybe important for people to know, and also to reflect on my own thinking as I was doing the interview and also about some of the things that I may have missed after having done the interview and having seen watch the video tape a couple of times. One of the things that I did not is in the case, in the Sandi’s case is how difficult it is for the reflecting team to react personally sometimes, but unknowingly to a family but to react to the overall therapeutic system although I may have emphasized that I find that sometimes it’s hard for therapists to think about the therapy system and not just the family. We are trying to observe the family and not to observe as interacting with the family and because it’s so compelling sometimes the story of the client, but I find that it is helpful to think about the relationship between the therapist and the family and some of the isomorphisms that happened there to understand what is happening in the family. In this case, one of the things that we find is that trauma occurs, I mean, at various levels. On the one side, you have the survival story, which is also at the same time a traumatic story. That is the husband, the father and the husband in this family will seem to have been very abusive towards his wife and the mother and towards the children. And that isn’t itself fairly traumatic. And then the survival story is leaving him and coming to the United States. And then, the second peace of this traumatic story is for the children to come to terms and for the mother to come to terms with having left one of the children in the home country. The other peace of the trauma is in itself the story of survival becomes — could become story of trauma as this family come and immigrate the United States. In the interview, we didn’t explore in detail the immigration story, we have enough time, because in some way, the conflict between the children and the mother, particularly one child and the mother, adult child takes over in terms of the interview, in terms of what becomes figure. And so, and then, as we — as that conversation moves along we’re moving to knowing little bit about acknowledging the trauma of coming to terms with the illness for mother. One of the things I did, I do in first interview of course, is to know who is in the family and try to build a basic genogram and that’s what I find myself doing in the first part of the interview. And also talking about how is it that they decide to come for a consultation. Conceptually a theme that I saw was interesting in this interview is the idea of leaving home, how is that this girl is struggling with independence, how mother is struggling with this independence. And how they are both in some ways struggling with the idea of dependence and independence and basically struggling with different notions of what it means to be independent or be dependent. And I would add that a lot of this course that is struggling with is that this course of how our society tends to see the kids leaving home, and tends to in some way, see independence as more important than dependence and work a lot around those polarities between dependents and independence rather think in terms of interdependence. And particularly now that they have to negotiate how mother is going to taking care by the children since she is getting ill. One of the things that I didn’t address in the interview is how the therapist define this process as detachment and I never addressed this idea of detachment, which is in itself, part of the process thinking about independence as separation rather than as joining. And it could have been, I think, I saw there was a last opportunity to talk about the therapist understanding of this process, since she understood it as detachment. One of the things that I also found myself doing a lot of was listening to the mother’s situation to the facts and the daughter, while they were showing some of the tension that existed between the two of them. And at the same time, as the competition evolve, I do acknowledge the emotional climate and how is it that in particular, the daughter is feeling in the session and at certain moment, she is very upset and sad and angry. And I knowledge that and maybe I too have acknowledged a little bit more mother’s emotional stands. One of the things that I didn’t also address that that doesn’t seem that the therapists could address later on is, how is that the daughter seems to know more about what’s going on with the siblings and to really validate her concern for the family in that way that in someway, she is being very protective of her mother as she takes care of the siblings. Another concern of mine and I think that I might have done that during the interview, was to always bring forth the voices of those who are present and those who are being represented in this case how, she, the daughter will represent the voices of the siblings. And another aspect of the interview includes how is it that I ask about social support and where is the family, what are the connections they have, and at the beginning, I ask about, is there is anybody else who immigrated with them and — or who is his close by as a relative. And at the end of the interview, I again suggest the possibility of thinking about social support, thinking of friends or other professionals or paraprofessionals who might provide support in particular around the new needs that mother, that the adult have right now in terms of the illness. The peace that was present in the session is this notion of agency. Although someone might have gone through a very traumatic period, I try to highlight the process of survival of overcoming that particular period and to think in terms of the future. And then think in terms of ambition and different kind of relationship and a couple of times in the interview I ask the mother and daughter to ambition how do they ambition in different kind of relationship. In the interviews, you can observe, and this is I think, basic in the collaborative approach, I often ask how — I mean, I check with the therapist and the clients around issues of how is this conversation moving, if this conversation were to continue this way, where will they go, and I ask the therapist to hypothesize what would happen if they were to continue talking in a particular way. During the reflecting theme, the basic conversation was around the dependence, independence and interdependence. And what I found very interesting is, how is it that the different place in the reflecting theme we’re able to understand the immigrant experience and the big cultural aspects of this family. And another piece that I saw that was important is to sort of like understand what it is to become more independent of your own parent while at the same time, coming to term with the notion that they would have — you would have to take care of your own parent, although this is in a very — at a early time, earlier than the usual. During the reflecting time, I thought to myself, I was reminded of how being close to the family coming from the same background, in this case, the therapist being also of some of from Iran may not necessarily ensure your success from a multi-cultural perspective. Although the relationship with the client maybe a very positive one and may not necessarily ensure the success and in that sense, the value of bringing the reflecting with very different voices. The peace that viewers may find interesting is, how I use words, in this case, the therapists, some are from Iran, I am also a non-English Irish speaker and how I use this an opportunity to play with words and to use humor with the family and the therapist, which I do often during the session. One of the questions I ask them and it will have different configuration with different families, I ask them who is more opinionated, who has a strong opinion, which in some way, is basically bringing — reflecting on something that could — we get them into trouble, something that will be seen as problematic, but at the same time, it maybe seen as validating. And when I ask who is more opinionated, a typical kind of secret questions I guess is, I’m basically, assuming that they are both opinionated that in a way they cheer some similarities, in fact, that with people are in conflict, often there’s, because they are seeing themselves as two different. And towards the end of the interview, I term on that I like her sense of humor and her daughter smile and I see how important it is to always validate both, any member, all the members of the family attending the session, so that the other one — so that the other one can feel okay about criticizing the other members of the family, but not having the therapist sort of like completely in coalition with that same statement. That is, if I can see and I can validate each members of the family, the other ones may also see that particular validation. Often in a consultation, I will mention that there’s themes that can be talked in therapy later and I may say maybe we can, I could have same, maybe, we can think about this idea between now and then if I were to be alone as a therapist. Often in a consolidation, I may say, this is something that maybe helpful to talk about in the future in a therapy session. I may say something of that sort in a reflective way. Another aspect that I noticed in this session like in many other sessions is, how expectations about the others, are they ones that may — high expectations about another member of the family might bring a lot of conflict. In terms of assimilation and I — towards the end I term on that she’d always be concerned about the children. And that there might be other ways, in which you can get resources. I also try to reframe some of the difficulties using multi-cultural framework, for instance, by saying that there is some things that you might be thinking here, that here it could be conservative, but in home country couldn’t because couldn’t be considered very radical and very different. And I also try to help them to think about this different transitions they are going through, including — and this different traumas they are dealing with in the past, in the present and in the future.
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Mother and Daughter: A Cultural Tale
INSTRUCTIONS ON HOW TO USE EXEMPLAR AND TEMPLATE—READ CAREFULLY
If you are struggling with the format or remembering what to include, follow the Comprehensive Psychiatric Evaluation Template AND the Rubric as your guide. It is also helpful to review the rubric in detail in order not to lose points unnecessarily because you missed something required. Below highlights by category are taken directly from the grading rubric for the assignments. After reviewing full details of the rubric, you can use it as a guide.
In the Subjective section, provide:
- Chief complaint
- History of present illness (HPI)
- Past psychiatric history
- Medication trials and current medications
- Psychotherapy or previous psychiatric diagnosis
- Pertinent substance use, family psychiatric/substance use, social, and medical history
- Read rating descriptions to see the grading standards!
In the Objective section, provide:
- Physical exam documentation of systems pertinent to the chief complaint, HPI, and history
- Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses.
- Read rating descriptions to see the grading standards!
In the Assessment section, provide:
- Results of the mental status examination, presented in paragraph form.
- At least three differentials with supporting evidence. List them from top priority to least priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
- Read rating descriptions to see the grading standards!
Reflect on this case. Include what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)
EXEMPLAR BEGINS HERE
CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why they are presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.
HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication, and referral reason. For example:
N.M. is a 34-year-old Asian male who presents for psychotherapeutic evaluation for anxiety. He is currently prescribed sertraline by (?) which he finds ineffective. His PCP referred him for evaluation and treatment.
P.H. is a 16-year-old Hispanic female who presents for psychotherapeutic evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her mental health provider for evaluation and treatment.
Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.
Paint a picture of what is wrong with the patient. This section contains the symptoms that is bringing the patient into your office. The symptoms onset, the duration, the frequency, the severity, and the impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders. You will complete a psychiatric ROS to rule out other psychiatric illnesses.
Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP.
General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.
Caregivers are listed if applicable.
Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?
Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)
Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. (Or, you could document both.)
Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.
Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information (be sure to include a reader’s key to your genogram) or write up in narrative form.
Psychosocial History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology. However, at a minimum, please include:
- Where patient was born, who raised the patient
- Number of brothers/sisters (what order is the patient within siblings)
- Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?
- Educational Level
- Work History: currently working/profession, disabled, unemployed, retired?
- Legal history: past hx, any current issues?
- Trauma history: Any childhood or adult history of trauma?
- Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)
Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.
Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.
Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines).
Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudo hallucinations, illusions, etc.), cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.
He is an 8 yo African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.
Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s treatment of the patient and why or why not. What did you learn from this case? What would you do differently?
Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
Case Formulation and Treatment Plan.
Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions with psychotherapy, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. *see an example below—you will modify to your practice so there may be information excluded/included—what does your preceptor document?
Initiation of (what form/type) of individual, group, or family psychotherapy and frequency.
Documentation of any resources you provide for patient education or coping/relaxation skills, homework for next appointment.
Client has emergency numbers: Emergency Services 911, the Client’s Crisis Line 1-800-_______. Client instructed to go to nearest ER or call 911 if they become actively suicidal and/or homicidal. (only if you or preceptor provided them)
Reviewed hospital records/therapist records for collaborative information; Reviewed PCP report (only if actually available)
Time allowed for questions and answers provided. Provided supportive listening. Client appeared to understand discussion. Client is amenable with this plan and agrees to follow treatment regimen as discussed. (This relates to informed consent; you will need to assess their understanding and agreement.)
Follow up with PCP as needed and/or for:
Write out what psychotherapy testing or screening ordered/conducted, rationale for ordering
Any other community or provider referrals
Return to clinic:
Continued treatment is medically necessary to address chronic symptoms, improve functioning, and prevent the need for a higher level of care OR if one-time evaluation, say so and any other follow up plans.
References (move to begin on next page)
You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.