CAP E-MODULE - OUTPATIENT SCENARIO

Browser lacks capabilities required to play.

Upgrade or switch to another browser.

Loading…

You have been working with an Asian American family whose son was hospitalized for First Episode Psychosis. The inpatient team completed the first break psychosis workup and all the labwork was normal. The inpatient team was able to start the patient on an antipsychotic. Andrew has since been discharged and is now seeing you in the outpatient setting. You and your team have been discussing the case and determined that the patient would benefit from therapy in addition to medication management. How can you explain the potential benefits of psychotherapy to Mr. and Mrs. Lee? [[Begin the visit ->BEGIN VISIT]]

The mother looks uneasy. "This all seems so overwhelming. I want to help Andrew, but I honestly don’t even know where or how to start." What are some things we can tell Cynthia about family therapy? What are the goals of family therapy and why is this important? Discuss the “Collectivism” idea in Asian families, and how this concept may change the approach of your conversation with Cynthia. [[Many parents feel scared and confused when this first happens. This is very common, and family therapy is designed to help families through this situation.->EXPLAIN FAMILY THERAPY]]

"What exactly is family therapy?" [[Family therapy is a space where you and your son can meet with a therapist together. It is meant to help you understand what Andrew is going through and learn ways to support him.->YOU MEET WITH A THERAPIST TOGETHER]]

You meet the family in the waiting room. They look a little uneasy but they look more comfortable with you compared to your first visit right after the patient's hospital admission. You bring the family back to your office with you. Andrew still has a constricted affect but is smiling a little more. He tells you that the voices are quieter now. [[That’s really good! It sounds like the medicine is doing its job. There’s one more thing I want to ask you about that I think could be helpful ->ONE MORE THING]]

The father cross his arms. "More? The pill is working!! Why more medications?" You agree that the pill is working. "The medication helps make the voices softer. But it doesn’t teach Andrew what to do with them, or how to live with them." Next, how should you talk to the family about therapy? [[Introduce individual therapy ->INTRODUCE INDIVIDUAL THERAPY]] [[Introduce group therapy ->INTRODUCE GROUP THERAPY]] [[Introduce family therapy ->INTRODUCE FAMILY THERAPY]]

You tell the family, "I’d like for Andrew to begin meeting with one of our therapists every 1-2 weeks. They could help him learn how to manage the remaining voices so they aren't so disruptful to his life." The mother looks confused. "How can just talking help? The hospital team said something is wrong with the chemicals in his brain! He cannot just change these chemicals by just talking about it." [[Therapy isn’t just talking. Think of it like swimming. Andrew is a swimmer, right? ->IT'S LIKE SWIMMING]]

Andrew: Well.. I’ve never met anyone like me before. It might be kind of nice. Do you want to discuss any of the other therapy options? [[Introduce individual therapy ->INTRODUCE INDIVIDUAL THERAPY]] [[Introduce family therapy ->INTRODUCE FAMILY THERAPY]]

The mother looks proud as she recalls her son's strengths. "He is very good at swimming, he placed number 1 last year." [[Therapy is like swim practice, every week, with the whole team. Every week, we practice. When a scary thought comes, how do you tell if it is a real danger, or a false alarm? Andrew learns how to differentiate between these experiences with a therapist, who acts like a coach, and then they can practice it together. ->COMPARE THERAPY TO SWIM PRACTICE]]

The mother starts to feel more open to the idea. "Like swim training. You are training his brain." Andrew, the patient, seemed interested. "I think I want to try it. Maybe it will help me go back to school." The father also agrees, "OK, fine we let him try it. We don’t tell anyone. No one else except our family and the doctor needs to know." [[Review feedback ->LEARNING POINT: DISCUSSING STRENGTHS AND RELATING EXPERIENCES TO FAMILIAR ONES]]

"Support him how? I already do everything for him. I cook for him, I clean his room, I drive him everywhere. What more can I do?" [[You should learn to communicate more calmly with Andrew and reduce stress at home.->YOU SHOULD BE MORE CALM]] [[It sounds like you already give so much of yourself to Andrew. Family therapy isn't about doing more, it's about learning what kind of support actually helps right now, and making sure you have support too.->LEARNING POINT: VALIDATE]]

Learning point: Validate the parent's effort before introducing new expectations, especially when the parent already feels she is failing. [[Try again? ->YOU MEET WITH A THERAPIST TOGETHER]]

*** [[CONTINUE->I DON'T FEEL LIKE I'M HELPING]]

"I don't feel like I'm helping. Every time I try, he gets angry, or he doesn't answer me at all." [[That's actually one of the biggest things family therapy can help with: learning how to talk with Andrew in a way that feels calm for both of you, even when things are hard. There are a few things we work on together in these sessions.->LEARNING HOW TO TALK WITH ANDREW]]

<<set _dialogue = [ "<strong>Provider: </strong>First, we help the whole family understand what psychosis actually is, what symptoms to watch for, and what tends to help versus what might make things harder without anyone meaning to.", "<strong>Mom: </strong>Like the weed?", "<strong>Provider: </strong>Exactly, things like that. Second, we work on communication, so how to talk to Andrew calmly and clearly, especially in moments of stress, and how to respond if his symptoms get worse.", "<strong>Mom: </strong>Okay, I see.", "<strong>Provider: </strong>Third, we look at lowering stress in the household overall. High stress at home can actually make psychosis symptoms worse, so learning to bring the tension down helps Andrew directly.", "<strong>Mom: </strong>So it's not just for Andrew?", "<strong>Provider: </strong>No and this is important. Family therapy is also a space for you. For you and your husband to talk about your own fears, and to learn how to take care of yourselves while you're taking care of Andrew. Parents often carry so much of this quietly. We don't want you carrying it alone.", "<strong>Mom: </strong>I haven't slept well in weeks. I keep thinking, what did I do wrong?" ]>> <<set _line = 1>> <div id="conversation"> <p><<print _dialogue[0]>></p> </div> <div id="continueButton"> <<button "Continue">> <<if _line < _dialogue.length>> <<append "#conversation">> <p><<print _dialogue[_line]>></p> <</append>> <<set _line += 1>> <<if _line >= _dialogue.length>> <<replace "#continueButton">> [[CONTINUE->PSYCHOSIS IS A MEDICAL CONDITION]] <</replace>> <</if>> <</if>> <</button>> </div>

You tell the mother, "I hear that question a lot from parents, and I want to say clearly that this is not something you caused. Psychosis is a medical condition, like diabetes or asthma, not something that happens because of a mistake a parent made. What you're doing right now, being here and asking how to help, that's part of what helps Andrew recover." [[Review feedback->LEARNING POINT: WHEN TO USE THE MEDICAL MODEL]]

Mom shares more about how she is feeling. "In our family, this is how it is. When something happens to one of us, it happens to all of us. Andrew's struggle is my struggle, his father's struggle. That's just how Chinese families are." [[I understand it feels that way, but it's important for Andrew to also learn to see this as his own journey. Part of therapy will be helping him build his own sense of identity separate from how the family sees him.->FOCUSING ON THE INDIVIDUAL]] [[I hear that, and honestly, I think that's a strength here. Andrew isn't facing this alone. He has you, he has his father, standing with him. So family therapy isn't just "help for Andrew." It's a space for your whole family, together. ->LEARNING POINT: FAMILY THERAPY IS ABOUT THE WHOLE FAMILY]]

Learning point: In many Asian families, family is seen as a primary unit rather than the individual: a child's experiences, struggles, and successes are shared by the family as a whole. Recognizing and affirming this collectivist framework, rather than imposing a more individualistic one, helps families feel understood and more receptive to the support being offered. [[CONTINUE ->BUT IF IT ALSO MEANS HE IS NOT DOING WELL]]

"But it also means if he is not doing well, people think we failed as parents. Arthur especially. He won't want to sit in a room and admit something is wrong with our son." [[That's a very real concern, and I understand why he might feel that way. I want to gently push back on one part though: needing extra support doesn't mean you failed. If anything, families who get involved early tend to see their child recover faster and stay more stable. Getting Andrew's whole family involved is one of the most protective things you can do for him. ->PROTECTIVE, HOW?]]

Mom: Protective how? [[Families who go through this kind of therapy together tend to see fewer relapses and fewer hospitalizations. It gives Andrew a stronger foundation to recover on. So the same closeness that makes this feel so heavy right now, that same closeness, once you all have the right tools, becomes one of Andrew's biggest sources of strength. ->FEELS LIKE A WEIGHT]]

"Strength? Right now it just feels like a weight on all of us." [[I understand why it feels that way. But I've seen it work the other way too: families who share everything, the hard parts and the good parts, tend to recover with a lot more resilience and hope than someone facing this completely alone. Andrew won't have to carry this by himself. He has a mother who makes him soup when he's struggling, a father who shows up even when he's scared and angry. That's not nothing, that's a foundation most patients don't have. ->I NEVER THOUGHT OF IT THAT WAY]]

"I never thought of it that way. So... what would this actually look like, if we started?" [[Discuss how family therapy is arranged ->ARRANGING FAMILY THERAPY]]

Typically we'd meet as a family once every week or two, here in the office, for about 45 minutes to an hour. Sometimes it's you and Andrew, sometimes the whole family together, depending on what feels most useful that week. Mom: And how do we start this? Is it hard to arrange? Not at all. I can put in the referral today before you leave, and our care coordinator will call you within the week to schedule the first appointment. It's covered the same way Andrew's other visits are, and if scheduling around work is difficult, we also offer some evening slots. Mom: Okay. I think... I think Arthur will come, if I tell him it's to help Andrew, not to blame anyone. That's a good way to frame it for him. This is about giving your family the tools to help Andrew heal together. Mom: Together... Okay let's do it. Do you want to discuss any of the other therapy options? [[Introduce individual therapy ->INTRODUCE INDIVIDUAL THERAPY]] [[Introduce group therapy ->INTRODUCE GROUP THERAPY]]

You tell the family, "I think it would be really helpful for Andrew to join a small group where he can meet other young people who share some of his experiences." The father crosses his arms. "Talking to other people about it? Who are the other people? Why should we meet and tell strangers what is going on with Andrew? Family issues should stay in the family. What if other people think Andrew is crazy? If other people find out they will gossip about him!" [[I want to be clear, everyone in the group has signed a promise to keep things discussed in the group private. Also, all the other kids in the group are experiencing something similar. They won’t think Andrew is strange or make fun of him, because they know what it is like. ->PRIVACY]]

Do you want to discuss any of the other therapy options? [[Introduce group therapy ->INTRODUCE GROUP THERAPY]] [[Introduce family therapy ->INTRODUCE FAMILY THERAPY]]

Learning point: Naming and directly addressing parental guilt is essential, especially in families where collectivist values may lead parents to feel personally and fully responsible for a child's illness [[CONTINUE ->TALKING ABOUT GUILT]]