Midterm Exam: NR605/ NR 605 (Latest Update 2024/2025) Diagnosis & Management in Psychiatric-Mental Health across the Lifespan I Practicum Review |Weeks1-4 Covered| Questions and Verified Answers| 100%Correct- Chamberlain

Midterm Exam: NR605/ NR 605 (Latest Update 2024/ 2025) Diagnosis & Management in Psychiatric-Mental Health across the Lifespan I Practicum Review |Weeks 1-4 Covered| Questions and Verified Answers| 100% Correct- Chamberlain Midterm Exam: NR605/ NR 605 (Latest Update 2024/ 2025) Diagnosis & Management in Psychiatric-Mental Health across the Lifespan I Practicum Review |Weeks 1-4 Covered| Questions and Verified Answers| 100% Correct- ChamberlainQ: Treatment Hierarchy Framework Answer: therapeutic aims at the base of the model must be addressed before the client can move up the triangle Top: Stabilization Internal resources External resources Bottom: Foundational needs Q: strategies to support resource development and stabilization: Answer: -case management -provision of safety -stress management -management of physiological arousal -exercise -cognitive or dialectical behavioral therapy -role play Q: Processing Answer:involves helping clients explore the meaning of adverse life events -adapting memory, cognition, behavior, affect, and beliefs surrounding traumatic events • achieve positive change Q: Cultural Considerations Answer: Culture shapes one's perceptions, attributions, emotions, and judgments in ways that are both conscious and unconscious -PMHNP must consider ethnicity, religion, race, class, cultural identity, and the cultural explanations of illness to effectively diagnose and treat mental health conditions -Outline for Cultural Formulation includes an assessment of the following categories: • cultural identity of the individual • cultural conceptualizations of distress • psychosocial stressors and cultural features of vulnerability and resilience • cultural features of the relationship between the individual and clinician • overall cultural assessment Q: Illness Perception Answer: psychodynamic approach -attributes mental illness to environmental and psychosocial problems biophysiological model -attributes mental illnesses to chemical imbalances of neurotransmitters Q: epigenetics Answer: the study of how the environment and other factors change the way genes are expressed Q: Documentation requirementsAnswer: -standard format of chief complaint, history of present illness, review of systems, past psychiatric history, mental status exam, diagnostic formulation, and treatment plan -Psychotherapy sessions must include the following: • target symptoms • goals of therapy • method of monitoring outcomes • frequency of treatment • clinical records to support relevant medical history • results of diagnostic tests or • procedures • prognosis or progress to date • estimated duration of treatment Q: Reimbursement Answer: Clinical procedural terminology (CPT) codes -standardized codes used to communicate services completed to Medicare and other insurance companies for reimbursement -PMHNPs can bill for stand-alone psychotherapy using psychiatry specialty codes • if the encounter includes diagnosing and/or prescribing medications, a medical evaluation and management (E/M) base code should be used with an add-on psychotherapy procedure code Q: Medical Evaluation and Management Codes Answer: specific five-digit E/M code -based on the type of client, location of service, and level of service XX=20 new client office/inpatient visit XX=21 established client office/outpatient visit XX=24 consultation for office/outpatient XX=22 inpatient care Q: Medical Decision MakingAnswer: level of medical-decision-making (MDM) is rated as straightforward, low, moderate, or high -based on three components: • number of diagnoses • amount of data being reviewed • risk of mortality/morbidity -The level of MDM is selected based on complexity Q: Psychotherapy Codes Answer: • 90832- psychotherapy duration 16-37 minutes • 90833- psychotherapy duration 16-37 minutes used as an add on code to a E/M code • 90834- psychotherapy 38-52 minutes • 90836- psychotherapy duration 38 or more minutes used as an add on code to a E/M code • 90837- psychotherapy 53 or more minutes • 90846- family psychotherapy client not present • 90847- family psychotherapy with client present • 90853- group psychotherapy Q: Lori, a 42-year-old female, presents to the office for an initial consultation. She has just experienced a breakup after a 5-year relationship and is feeling "depressed." A comprehensive initial evaluation which includes chief complaint, history or present illness, medical history, previous psychiatric history, family history and a comprehensive review of systems was completed. Psychotherapy was included in the session - 18 minutes time. provide the appropriate CPT code Answer: 99205+90833 Rationale: The client is new to the practice (20) and presents with one problem which addressed 4 or more elements, had a comprehensive history and interview. No additional testing was needed, treatment was initiated (05). Psychotherapy was included in the session- 18 minutes time. Therapy goals were established and reviewed with the client.Q: Hannibal, a 23-year-old male, is admitted to an inpatient psychiatric facility with symptoms of auditory hallucinations, paranoia, and suicidal ideations. A comprehensive initial evaluation which includes chief complaint, history or present illness, medical history, previous psychiatric history, family history and a comprehensive review of systems was completed. provide the appropriate CPT code Answer: 99223 Rationale: The client presents for initial hospital care (22) and has a high level of medical decision-making due to an acute illness that poses a threat to life (3). Q: Shakina, a 19-year-old transgender female, has been referred to the PMHNP from primary care. The PMHNP reviews the primary provider's note and identifies symptoms of bipolar I disorder. The PMHNP completes a comprehensive assessment and prescribes medications for the client. provide the appropriate CPT code Answer: 99245 Rationale: The client has been referred (24), has complex medical decision-making needs (5) based on one undiagnosed new problem with an uncertain prognosis, required review of referral notes, and requires prescription drug management. No psychotherapy provided. Q: Steve, a 30-year-old married client returns for a follow up appointment. He was initially seen 3 months ago due to increased anxiety over his marriage. His diagnoses include generalized anxiety disorder (F41.1) and major depressive disorder (F32.1) The PMHNP has provided both medication management and cognitive behavioral therapy (CBT). Today the PMHNP obtains a chief complaint, history of present illness, reviews medical history, and a focused review of three systems was completed. Medications were renewed and 18 minutes of psychotherapy (CBT) was provided) to include review of therapy goals and progress to date was documented. provide the appropriate CPT code Answer:99214 + 90833 Rationale: This is a returning client with two documented diagnoses. A focused encounter was conducted that included psychotherapy. Q: The PMHNP has initiated a grief support group at her practice. The support group is one hour in length and can include the client and family members. provide the appropriate CPT code Answer: 90853 Rationale: This is group psychotherapy with no medication management. Only a psychotherapy code is necessary. Q: Interprofessional Collaboration and Referrals Answer: -PMHNPs may receive client referrals from primary care providers to address mental health problems -refer clients to primary care providers for medical care -PMHNPs may collaborate with social workers to address clients' needs for social support -vocational counselors to assist with employment needs -refer clients to other therapists • geriatrics, psychiatric emergencies, eating disorders, family therapy, or pediatrics -telehealth services or a support group Q: Disparities in Mental Health Services Answer: Racial, ethnic, gender, and sexual minorities -often experience poor mental health outcomes due to inaccessibility of quality mental health services, discrimination, a cultural stigma surrounding mental health care, and lack of knowledge about mental health• To address disparities, the American Psychological Association (2022) advocates for the expansion and use of culturally and linguistically competent psychological and behavioral research and services Q: Legal & Ethical Considerations Answer: Provider initiated termination for cause Termination letters Court mandated treatment Process and progress notes Q: Code of Ethics for Nurses Answer: Respect for the Individual Commitment to the Healthcare Consumer Advocacy for the Healthcare Consumer Responsibility and Accountability for Practice Duties to Self and Others Contributions to Healthcare Environments Advancement of the Nursing Profession Collaboration to Meet Health Needs Promotion of the Nursing Profession Q: A client who is alert and oriented declines the PMHNP's treatment recommendation for an antipsychotic in a non-emergent situation. Informed consent required Exception to informed consent Answer: Informed consent required Rationale: The client has the capacity to consent and the situation is not emergent. The ethic of autonomy provides for the client to refuse treatment options.Q: An agitated, hallucinating client with a diagnosis of schizophrenia and no designated decision-maker threatens to shoot his neighbors. The client acts out violently towards the security guard in the emergency department. The PMHNP orders haloperidol and lorazepam for the client. Exception to informed consent Informed consent required Answer: Exception to informed consent Rationale: The client does not have the capacity to provide consent. Q: A very anxious client is seeking treatment for anxiety symptoms. When the PMHNP begins to explain the treatment options, the client says she is too anxious to hear them and asks that the PMHNP select the best option. Exception to informed consent Informed consent required Answer: Exception to informed consent Rationale: Clients may choose to waive their right to informed consent. Q: A client with depression is unhappy about the performance of the anti-depressant that has been prescribed and would like to discuss alternate treatment options with the PMHNP. Informed consent required Exception to informed consent Answer: Informed consent requiredRationale: Clients have a right to information about treatment options with associated risks and benefits. Q: Circumstances that increase suicide risk: Individual Risk Factors Answer: Previous suicide attempt History of depression and other mental illnesses Serious illness such as chronic pain Criminal/legal problems Job/financial problems or loss Impulsive or aggressive tendencies Substance use Current or prior history of adverse childhood experiences Sense of hopelessness Violence victimization and/or perpetration Q: Circumstances that increase suicide risk: Relationship Risk Factors Answer: Bullying Family/loved one's history of suicide Loss of relationships High conflict or violent relationships Social isolation Q: Circumstances that increase suicide risk: Community Risk Factors Answer: Lack of access to healthcare Suicide cluster in the community Stress of acculturation Community violence Historical trauma DiscriminationQ: Circumstances that increase suicide risk: Societal Risk Factors Answer: Stigma associated with help-seeking and mental illness Easy access to lethal means of suicide among people at risk Unsafe media portrayals of suicide Q: Circumstances that protect against suicide risk: Individual Protective Factors Answer: Effective coping and problem-solving skills Reasons for living (for example, family, friends, pets, etc.) Strong sense of cultural identity Q: Circumstances that protect against suicide risk: Relationship Protective Factors Answer: Support from partners, friends, and family Feeling connected to others Q: Circumstances that protect against suicide risk: Community Protective Factors Answer: Feeling connected to school, community, and other social institutions Availability of consistent and high quality physical and behavioral healthcare Q: Circumstances that protect against suicide risk: Societal Protective Factors Answer: Reduced access to lethal means of suicide among people at riskCultural, religious, or moral objections to suicide Q: warning signs for suicide: Answer: Talking about being a burden Being isolated Increased anxiety Talking about feeling trapped or in unbearable pain Increased substance use Looking for a way to access lethal means Increased anger or rage Extreme mood swings Expressing hopelessness Sleeping too little or too much Talking or posting about wanting to die Making plans for suicide Q: Phases of Therapy Answer: Initiation Working Termination Q: Initiation of Therapy Answer: -one of the most important goals of the first session is establishing a therapeutic alliance • fundamental component of successful therapy -comprehensive history & mental status examination • collect info to establish a psychiatric history and dx • guide the development of a tx plan -location, frequency of sessions, and payment -safety, primary consideration in psychotherapy• safety assessment should be conducted in the initial session, questions regarding suicidal and homicidal thoughts and thoughts of self-harm • collaboratively written safety plan should be created for any client identified to be at risk for self-harm Q: suicide Answer: -a leading cause of death in the U.S. -In 2020, suicide was the: • 12th leading cause of death overall • 2nd leading cause of death among individuals between the ages of 10 and 34 • 3rd leading cause of death among individuals between the ages of 35 and 44 -clients with mental health diagnoses such as mood disorders, psychotic disorders, and substance use disorder are at particularly high risk • 50% of those who die by suicide do not have a previous psychiatric history Q: safety plan includes: Answer: a prioritized list of coping strategies and resources the client can use when thinking about suicide or self-harm Q: Implementing the Safety Plan: 6 Step Process Answer: Step 1: Warning Signs Step 2: Internal Coping Strategies Step 3: Social Contacts Who May Distract from the Crisis Step 4: Family Members or Friends Who May Offer Help Step 5: Professionals and Agencies to Contact for Help Step 6: Making the Environment Safe Q: A no-suicide or no-harm contract:Answer: -not a legal document but rather an agreement between the client and therapist about what the client should do if they become suicidal -involves a commitment by the client to not commit suicide. -may not be effective in a crisis and is not a substitute for clinical judgment. -only as beneficial as the therapeutic alliance Q: frame of the relationship Answer: rules and boundaries -psychotherapist is responsible for setting and keeping the frame during therapy sessions -Common elements: • process for contacting the provider • what to do in case of an emergency • adherence to a schedule • fees • confidentiality • boundaries of the therapeutic relationship • whether eating & drinking during the session are appropriate • whether session interruptions are allowed • whether phone calls between sessions are acceptable • starting and stopping on time Q: establishing a psychotherapeutic environment Answer: -Safe and therapeutic -Boundaries -Rules -Environment -Contact Processes -Emergency Plan -Miscellaneous -AdherenceQ: Setting Goals and Duration of Therapy Answer: -overall goal of psychotherapy is to help clients gain self-awareness and decision-making -psychotherapy is goal-directed • Goal-setting should be a collaborative process between the therapist and the client -duration of therapy varies • common for therapy to last for at least 3-4 months • client's financial situation & insurance coverage may also impact the duration of therapy Q: Practical considerations for psychotherapy Answer: scheduling -outpatient therapy, sessions are typically scheduled in 45 to 50-minute blocks -permits time between sessions to document and prepare for the next -initial intake session may be up to 90 minutes -inpatient psychotherapy will vary based on unit scheduling & ind client needs. Fees -Fees & payment options should be discussed during the initial visit -private practice typically collect insurance co-pays or fees directly -PMHNPs who work within a larger health system may not be responsible for discussing or collecting fees from clients -discuss charges for missed sessions as well as the required notification to prevent charges confidentiality -paramount to establishing a therapeutic alliance -Providers must abide by the standards set by HIPAA as well as any applicable state laws • must provide clients with information regarding HIPAA and explain what information will be shared and with whom -mandated to report concerns of threat of harm to self or others and child abuse. Q: Psychotherapy Contracts Answer: not required to begin therapy -best practice is to provide a written therapy contract detailing:• terms of the therapeutic relationship • scheduling • missed appointments • fees • confidentiality • termination Q: setting for psychotherapy Answer: -Create a warm, welcoming, and safe environment -tissues available -clock where it is visible by both therapist and client -ensure client and provider safety -Therapist should avoid sitting behind a desk • instead sit 3-4 ft. away but not directly across from client. -Office uses neutral décor Q: working phase of therapy Answer: -when therapeutic interventions typically take place. -content of the working phase is driven by: • client's diagnosis • identified goals • selected treatment modality Q: Termination Answer: number of therapy sessions is often dependent on the type of therapy -CBT typically engage in 5-20 sessions -Discussion of therapy termination should begin at the initiation of therapy -Ideally, when goals have been met, the client and therapist mutually decide to terminate the therapy relationship -client can choose to terminate non-court-ordered therapy at any time-Reasons for premature termination include: • inability to afford therapy • feelings that therapy is no longer beneficial • relocation out of the therapist's service area Q: The PMHNP can take steps to prevent client-initiated premature termination. Which strategies can be used to help promote the completion of therapy? Select all that apply. express confidence in the client for seeking therapy assign homework for each session describe the planned duration of therapy during the initial session strengthen the therapeutic alliance educate the client on their role in the therapy sessions discuss progress at the end of the last session Answer: -express confidence in the client for seeking therapy -describe the planned duration of therapy during the initial session -strengthen the therapeutic alliance -educate the client on their role in the therapy sessions Rationale: Providing education to clients about their role in the therapeutic process and the expected duration of therapy, strengthening the therapeutic alliance, and strengthening client hope by expressing confidence can help reduce premature termination by the client. Although assigning homework for each session is an acceptable strategy for therapy, client preferences should be considered. Therapy progress should not be limited to the last session but should be incorporated regularly throughout therapy. Q: Termination for Cause Answer: provider must ensure that legal and ethical obligations towards the client are met -client's needs are beyond the scope of the provider's competence or license, the provider may refer the client and terminate therapy -PMHNP changes employment or moves, they have a responsibility to provide a referral to another provider -Providers may consider termination for noncompliance or missed sessions -client presents a safety risk to the provider and the provider is unwilling to meet with the client in person, termination may be appropriate-Failure to pay or insurance authorization denial is not acceptable grounds for termination during a crisis -PMHNP should prepare a termination letter that delineates the reasons for termination and provides recommendations regarding further treatment if of the letter should be retained in the client's records. Q: Court-Mandated Treatment Answer: -require treatment for individuals or families. -Mandated therapy may be ordered as an alternative to jail for clients with mental health or substance use disorders -Parents may be compelled to attend therapy during a divorce trial or as a stipulation to regain custody after allegations of abuse or neglect -Sex offenders may also be obligated to attend mandated therapy -Clients who fail to meet the requirements of court-mandated therapy may be found in contempt of court or be required to serve jail time -Confidentiality • provider may be required to share information with the court • must frankly discuss the limits of confidentiality with the client Q: psychotherapy documentation: Provider Responsibilities Answer: Clinical Management -Informs the provision of care and provides a review of past proceedings -Supports the continuity of care when referrals or interdisciplinary care occurs Legal Implications -Records may be shared during civil proceedings, such as for divorce or custody cases -Courts may subpoena records for criminal proceedings -Court-ordered counseling records may be shared with the court Risk Management -Documentation of high-risk situations can be protective in litigation and should include: • situation • severity of threat • all possible interventions considered • colleague consultations• intervention implemented • follow-up Q: Process Notes versus Progress Notes Answer: Process notes -personal tool for the therapist to record thoughts, feelings, observations, or hypotheses during or immediately following the session -private; Clients, other providers, and insurance companies may request access to process notes; however, the provider is not obligated to share them except in limited situations Progress notes -contain treatment plan: history, diagnosis, medication details, and progress summaries -considered a part of the medical record and may be shared, as appropriate, with other providers, insurance companies, and the client. Q: Ruben is a 36-year-old who has been in therapy for 5 months. He is in the process of divorcing his wife of 12 years and is seeking custody of his daughter. His attorney has requested copies of his psychotherapy notes to use in support of the custody hearing. Can the therapist choose to share the psychotherapy notes? Yes, no client authorization necessary Yes with written authorization from the client No Answer: Yes with written authorization from the client Rationale: the client must provide written authorization for his notes to be shared with his attorney. Q: Kathy is a 32-year-old who has been in court-mandated therapy for two months after her children were removed from the home by Child Protective Services for suspected physical abuse and neglect. The social worker has requested copies of her progress notes as a part of the investigation. Is the therapist obligated to provide the progress notes?Yes, no client authorization necessary Yes with written authorization from the client No Answer: Yes, no client authorization necessary Rationale: Because the notes were requested for a health and human services investigation, the therapist may release the notes without client authorization. Q: Juanita is a 17-year-old who has been in therapy for 3 months for major depressive disorder. Her mother is requesting a copy of her psychotherapy notes so she can better understand the progress her daughter is making. Juanita has indicated that she is "ok" with her mom accessing the notes. Is the therapist obligated to provide the psychotherapy notes? Yes, no client authorization necessary Yes with written authorization from the client No Answer: No Rationale: Even though the client may authorize the release of notes to her parent, the therapist is not obligated to release the process notes to the client or her mother if they feel it is not in the best interest of the client. Q: Raghu is a 22-year-old who has been in therapy for two years. Recently, he was arrested on charges of assault with a deadly weapon. The therapist receives a subpoena from the court with requests for his progress notes. Is the therapist obligated to provide the progress notes? Yes, no client authorization necessary Yes with written authorization from the client No Answer: Yes, no client authorization necessary Rationale: The therapist must obey the court subpoena and provide the progress notes. Psychotherapy notes may still fall under therapist-client privilege and may be withheld from thecourt; in this case, the therapist should seek legal counsel to ensure proper compliance with the subpoena. Q: therapeutic communication Answer: -Translating emotions • Sharing observations • Sharing empathy • Sharing hope • Sharing humor • Sharing feelings -Non-verbal communication • Active Listening • Using touch • Using silence -Information verification/dissemination • Providing information • Clarifying • Focusing • Paraphrasing • Validation • Asking relevant questions Q: nontherapeutic techniques Answer: Asking for Explanations -Why are you so anxious? Asking Personal Questions -Why don't you and John get married? Giving Advice -If I was you, I'd take a break from school. Disapproval -You shouldn't even think about assisted suicide; it's not right.Defensive Responses -No one here would intentionally lie to you. False Reassurance -Don't worry, everything will be all right. Q: Therapeutic techniques Answer: Broad Openings -What would you like to talk about today? Reflecting -What do you think you should do about it? Presenting Reality -I don't see anyone else in the room. Sympathy -I'm so sorry about your mastectomy; it must be terrible to lose a breast. Summarizing -Today we have talked about a plan for you to manage feelings of anger. Making an Observation -You seem upset about something. Q: Which theory would the psychiatric mental health nurse practitioner (PMHNP) most need to consider when conducting a psychiatric interview in the following situations? A 35-year-old homeless client is in the emergency department with suicidal ideations. Hierarchy of Needs Theory Psychosocial Development Theory Cognitive Development Theory Answer: Hierarchy of Needs TheoryRationale: To attend to higher-level needs, a client must first meet foundational needs. A homeless client may be struggling to meet physiological and safety needs. Q: Which theory would the PMHNP most need to consider when conducting a psychiatric interview in the following situations? A 14-year-old foster child struggling to develop trusting relationships with his foster parents. Hierarchy of Needs Theory Psychosocial Development Theory Cognitive Development Theory Answer: Psychosocial Development Theory Rationale: According to Erickson's theory, a developmental crisis in infancy trust vs. mistrust. When basic trust in caregivers is not developed in early life, it can impact the creation of trusting relationships later. Q: Which theory would the PMHNP most need to consider when conducting a psychiatric interview in the following situations? A 4-year-old is struggling to understand what she has seen on television about civil protests. Hierarchy of Needs Theory Psychosocial Development Theory Cognitive Development Theory Answer: Cognitive Development Theory Rationale: According to Piaget, children in early childhood do not have the cognitive ability to understand abstract concepts, such as justice. Q: Erikson's psychosocial stages: Answer: -Infancy: Trust vs. Mistrust (birth-18 months)-Early Childhood: Autonomy vs. Shame and Doubt (ages 18 months-2 to 3 years) -Preschool: Initiative vs. Guilt (ages 3-5) -School Age: Industry vs. Inferiority (ages 6-11) -Adolescence: Identity vs. Role Confusion (ages 12-18) -Young Adulthood: Intimacy vs. Isolation (ages 19-40) -Middle Adulthood: Generativity vs. Stagnation (ages 40-65) -Maturity: Integrity vs. Despair (ages 65-death) Q: Psychoanalytic theory Answer: Freuds theory of personality -childhood experiences & unconscious desires influence behavior -libido, fixation stuck at psychosexual development stages • predicts adult personality Q: The Therapeutic Alliance Answer: the cooperative, purposive working relationship that exists between the psychotherapist and the client -essential factors: • agreement on the goals, tasks, & strategies of tx • bond between the provider & the client -strong therapeutic alliance is crucial to the success of therapy -foundations of a therapeutic alliance: • trust, connection, and rapport Q: Provider characteristics that help build the therapeutic alliance:Answer: -empathy -genuineness -warmth -acceptance -a collaborative approach to goal-setting -strong communication skills -Unconditional positive regard Q: Hildegard Peplau Theory of Interpersonal Relations in Nursing Answer: defined nursing as an interpersonal therapeutic process in which nurses engage in therapeutic relationships with individuals in need of health services -Peplau is considered to be the "mother of psychiatric nursing" • her work is foundational to the development of the PMHNP role in psychotherapy -emphasized the need for self-awareness in the nurse-client relationship • critical to ensure that the therapist will act in the client's interests -nurse-client relationship has four sequential phases: • orientation • identification • exploitation • resolution Q: Hildegard Peplau therapeutic relationship six nurse roles Answer: • Stranger: Nurse creates an environment to build trust • Teacher: Nurse imparts relevant knowledge and provides instructions and training • Resource person: Nurse provides specific information needed by the client, answers questions, and interprets clinical data • Counselor: Nurse helps the client understand and integrate meaning into life's circumstances, provides guidance and encouragement for change • Surrogate: Nurse helps clarify domains of dependence, interdependence, and independence and acts as an advocate for the client• Leader: Helps client take maximum responsibility for meeting treatment goals Q: therapeutic alliance Boundaries Answer: create a formal structure and set of rules or limits that help provide a safe relationship between the provider and client -may include the psychotherapist's self-disclosure, the therapeutic use of touch, exchange of gifts, fees, timing, and location of therapy sessions, and contact outside of the office Q: Self-Disclosure Answer: when the psychotherapist shares personal rather than professional information with the client -used sparingly with care for the benefit of the client • can contribute to the building of trust & empathy & can strengthen the therapeutic alliance -overuse can remove the focus from the client -Inappropriate self-disclosure can lead to a role reversal between the psychotherapist and the client • client feels the need to take care of the provider • boundary violation Q: Transference Answer: when a client directs their feelings towards a significant person in their lives -such as a parent, or a psychotherapist -typically unconscious -may be positive or negative -may provide perspective into client's relationships & offer an opportunity to help the client gain insight Q: CountertransferenceAnswer: psychotherapist's conscious or unconscious reactions to a client based on their own psychological needs or conflicts -can have a negative impact on the therapeutic alliance • if boundaries between the psychotherapist and the client are blurred and the psychotherapist loses perspective -can undermine trust in the therapeutic alliance Q: A client and her husband approach the psychotherapist at a mutual friend's party. The client introduces her husband to the provider who returns the greeting. May or may not be a boundary violation Boundary violation Not a boundary violation Answer: Not a boundary violation Rationale: This is not a boundary violation because the client approached the psychotherapist. If the psychotherapist approached the client, it would be a boundary violation Q: A psychotherapist holds the client's hand during the client's retelling of a traumatic event after the client reaches out. May or may not be a boundary violation Boundary violation Not a boundary violation Answer: Not a boundary violation Rationale: This is not a boundary violation. Touch may be therapeutic in certain situations. Q: A psychotherapist agrees to a blind date with a client's sister.May or may not be a boundary violation Boundary violation Not a boundary violation Answer: May or may not be a boundary violation Rationale: This may or may not be a boundary violation depending on whether the client is a current client. Refer to state-specific guidelines for information about boundaries with former clients. Q: A psychotherapist was in a car accident and needs auto body work completed. When the psychotherapist arrives at the auto body shop suggested by the insurance company, she realizes that the shop is managed by one of her clients. The psychotherapist schedules the needed repairs. May or may not be a boundary violation Boundary violation Not a boundary violation Answer: May or may not be a boundary violation Rationale: This may or may not be a boundary violation. Dual relationships may be problematic; however, if the psychotherapist resides in a small town and the body shop is the only shop approved by insurance, it may not be a boundary violation. Q: A client has a florist shop in town. The psychotherapist needs to send an arrangement to a friend and typically orders from another shop when he remembers that his client owns a shop. He orders the flowers from the client's shop. May or may not be a boundary violation Boundary violation Not a boundary violation Answer: Boundary violation Rationale: This is probably a boundary violation. It's helpful to avoid dual relationships when possible.Q: A psychotherapist shares her history of sexual assault with a client who has had a similar experience. May or may not be a boundary violation Boundary violation Not a boundary violation Answer: May or may not be a boundary violation Rationale: This may or may not be a boundary violation. Some forms of psychotherapy may include self-disclosure as part of the therapeutic alliance. Q: Psychodynamic Therapy Answer: a form of talk therapy that helps clients to better understand the thoughts, feelings, and conflicts that contribute to behavior -grew out of the 19th-century work and theories of Sigmund Freud -client's past relationships may be reenacted in the present Q: Sigmund Freud Answer: considered to be the father of psychoanalytic psychotherapy -ID'd three levels of awareness: • preconscious • conscious • unconscious -theory postulates that all actions are based on unconscious sexual or aggressive drives -Psychological symptoms result from conflicts between three parts of the mind: • id • ego • superegoQ: Id: Answer: Primitive instinctive unconscious basic urges seeks pleasure demands immediate satisfaction Q: Ego: Answer: Rational logical mostly conscious allows the mind to satisfy id's urges appropriately and safely moderates between id and superego Q: Superego: Answer: A sense of right and wrong both conscious and unconscious internalized morals Q: psychosexual stages of development Answer: Oral stage: 0-1 yr Anal stage: 2-3 yrPhallic stage: 3-6 yr Latency stage: 6 yr to puberty Genital Stage: Beyond puberty Q: Erik Erikson psychosocial stages of development Answer: expanded the developmental theory to encompass the full lifespan rather than just childhood and adolescence -conceptualized development in terms of psychosocial rather than psychosexual crises/conflicts -successful resolution of each conflict is necessary to move successfully from stage to stage -8 stages Q: key principles of psychodynamic therapy Answer: -unconscious motivations affect behavior -past experiences shape personality -past experiences affect the present -developing insight into patterns of behavior, feelings, relationships can help with psychological issues -transference can help the individual work through past issues -freedom from the past can help improve life in the future Q: Defense Mechanisms Answer: tactics to protect the ego from anxiety -Displacement -Denial -Sublimation -Projection -Regression -Repression-Rationalization -Intellectualization Q: Aleksander received an inferior performance evaluation at work. When he arrived home after a long day, he shouted at his 3-year-old daughter for leaving her toys out in the playroom. -Displacement -Denial -Sublimation -Projection -Regression -Repression -Rationalization -Intellectualization Answer: Displacement Displacement occurs when a person expresses an emotion, such as anger or frustration, towards a "safe" person rather than towards the cause of the emotion. Q: Frieda drinks 5-6 alcoholic beverages each night when she comes home from work. She typically drinks until she passes out; however, she never drinks during the day and never misses work due to her drinking, though her drinking has impacted her relationship with her spouse. She does not believe that her drinking is a problem because she goes to work and pays bills on time. -Displacement -Denial -Sublimation -Projection -Regression -Repression -Rationalization -Intellectualization Answer: Denial Denial occurs when a person refuses to admit to reality or an obvious fact.Q: Gabriella presents to therapy with concerns about anxiety and difficulty forming relationships. She suffered childhood abuse; however, she has little memory of the incidents. -Displacement -Denial -Sublimation -Projection -Regression -Repression -Rationalization -Intellectualization Answer: Repression Repression occurs when painful memories are "forgotten." The memories become subconscious and continue to impact behavior. Q: Ahmad recently experienced a nasty breakup with his girlfriend after she cheated on him. While he would like to call her to vent his anger and frustration, instead, he channels his energy into training for a marathon. -Displacement -Denial -Sublimation -Projection -Regression -Repression -Rationalization -Intellectualization Answer: Sublimation Sublimation occurs when a person transfers unacceptable impulses into socially acceptable forms.Q: Anderson has been having an affair with his secretary at work. He has become highly suspicious of his wife and frequently accuses her of being attracted to her boss. -Displacement -Denial -Sublimation -Projection -Regression -Repression -Rationalization -Intellectualization Answer: Projection Projection involves ascribing one's feelings to another person. Q: Cieran's boss is routinely rude and abrupt with him. Today she accused him of arriving late to work though he was on time. Rather than confront his boss, Cieran wonders whether his boss has difficulties at home that make her irritable. -Displacement -Denial -Sublimation -Projection -Regression -Repression -Rationalization -Intellectualization Answer: Intellectualization Intellectualization occurs when a person uses intellectual thought or learning to suppress an emotional aspect of a situation. Q: Levi asked his coworker Marilyn out on a date. She declined the invitations. When telling his friend about the incident, he states he wasn't all that attracted to her anyway.-Displacement -Denial -Sublimation -Projection -Regression -Repression -Rationalization -Intellectualization Answer: Rationalization Rationalization involves creating rational explanations to avoid the emotional consequences of a situation. Q: Ramona is sexually assaulted when walking home from work late at night. Following the assault, she begins sucking her thumb for comfort. -Displacement -Denial -Sublimation -Projection -Regression -Repression -Rationalization -Intellectualization Answer: Regression Regression occurs when a person reverts to early developmental coping mechanisms based on Freud's stages of psychosexual development. Q: Training and Certification Requirements for psychodynamic psychotherapy Answer: must complete additional post-master's level training -rograms vary in length from two to four yearsQ: Psychodynamic Continuum Answer: continuum from supportive and stabilization therapy to expressive and psychoanalytic therapy -supportive end of the continuum, therapy is focused on stabilization through anxiety reduction, defense stabilization, and improved problem-solving -the psychoanalytic end, therapy is directed at interpreting unconscious conflict and gaining insight -Expressive therapies are focused on emotional processing Q: Types of Psychodynamic Psychotherapy Answer: Psychoanalysis Supportive Psychotherapy Expressive Psychotherapy Brief Psychodynamic Therapy Q: Psychoanalysis Answer: -Indications: commonly used for anxiety disorders, OCD, depressive disorders, personality disorders, & sexual dysfunction -goals: development of a deeper understanding of self and a desire to create change -Contraindications: not motivated, poor impulse control, concrete thinkers, those amid a major physical or emotional crisis -tends to be more intense than other forms of psychotherapy in terms of the frequency of sessions and the intense nature of the transference that occurs • several sessions per week over several years -variety of techniques • recollection • repetition • working through • free association • transference • interpretationQ: Supportive Psychotherapy Answer: -an approach used to help clients who are experiencing emotional distress or problems in living -appropriate for clients experiencing specific stressful situations: • psychotic personality organization • preoccupied or overly emotional attachment style • those with immature defenses -goals of therapy: problem-solving, management of feelings and life stressors, and symptom relief -used for: • stabilization • resource building • anxiety reduction • problem-solving -Therapeutic Techniques: providing comfort, encouragement and reassurance, and empathic listening Q: Expressive Psychotherapy Answer: -appropriate for clients with unresolved, disorganized attachment styles and clients with a neurotic defense schema -along with dialectical behavioral therapy, is the preferred form of psychotherapy for clients with a borderline personality disorder or borderline character structure -goals: processing of relational trauma and learning emotional self-regulation -sessions typically several times per week -Therapeutic Techniques: • transference • counterconditioning • desensitization to past traumatic relationships Q: Brief Psychodynamic Therapy Answer:-used when the client has a specific issue or conflict such as difficulty in relationships, school or work, or communication. -time-limited form of psychotherapy • occurs fewer days per week over a shorter length of time • typically 20-30 sessions with a termination date set at the beginning of therapy -Goals: enhancement of self-awareness and understanding the impact of the past on present behavior -Therapeutic Techniques: pressure, or encouragement, to examine feelings and situations; challenge to defenses, and head-on collision to overcome defenses. Q: Sofia is a 32-year-old new mom who presents for therapy. She states that her relationship with her mother has always been "terrible," and she wants to identify patterns and behaviors in that relationship so that she does not "repeat history" with her child. She is not exactly sure why she and her mother do not get along well, and she is willing to commit to long-term therapy. Which of the psychodynamic psychotherapies below is best suited for Sofia? expressive psychotherapy brief psychodynamic therapy psychoanalytic psychotherapy supportive psychotherapy Answer: psychoanalytic psychotherapy Rationale: Sofia presents with a desire to create lasting change and is willing to commit to longterm therapy. Her deep-rooted relationship issues with her mother may best be addressed in psychoanalytic psychotherapy. Q: Tiffany is a 24-year-old who presents for therapy after encouragement from her sister. She endorses difficulty forming close relationships and admits to sexually promiscuous behavior regularly. During the intake interview, she discloses a history of physical abuse by both parents; she has never admitted the abuse to anyone but her sister. She also admits to cutting as a coping strategy. Which of the psychodynamic psychotherapies below is best suited for Sofia? expressive psychotherapy brief psychodynamic therapy psychoanalytic psychotherapy supportive psychotherapyAnswer: expressive psychotherapy Rationale: Tiffany presents with behaviors consistent with borderline personality structure, including difficulty forming relationships, acting out via sexually promiscuous behavior, and self-harm. Expressive psychotherapy can assist Tiffany with reliving her past trauma and activating emotions to begin the healing process. Q: Terrell is a 40-year-old who presents for therapy. He is recently separated from his partner of 10 years, and he tearfully states that thinking about returning to dating is "horrifying," but he expresses anxiety about "being alone for the rest of my life." Which of the psychodynamic psychotherapies below is best suited for Sofia? expressive psychotherapy brief psychodynamic therapy psychoanalytic psychotherapy supportive psychotherapy Answer: supportive psychotherapy Rationale: Terrell presents with an emotional communication style, life stressors related to a recent breakup, and anxiety related to change. Supportive psychotherapy will help Terrell problem solve, reduce anxiety, and build appropriate resources. Q: Olathe is a 26-year-old who presents for therapy related to relationship issues with her spouse. She states that their communication has been "nonexistent" for several months and that she is "at the point where divorce seems like the only option." While she verbalizes understanding that therapy is not a "quick fix," she indicates that she would like to learn communication tools that she can use immediately. Which of the psychodynamic psychotherapies below is best suited for Sofia? expressive psychotherapy brief psychodynamic therapy psychoanalytic psychotherapy supportive psychotherapy Answer: brief psychodynamic therapyRationale: Olathe presents with a specific conflict that is related to communication with her spouse. Because she is interested in pursuing therapy to address this specific conflict and learn new communication tools, brief psychodynamic therapy to challenge and overcome her defenses is a good option. Q: humanistic-existential approach Answer: -foundational to psychiatric mental health nursing • central tenets of holism, self-actualization, and the therapeutic alliance -places emphasis on understanding human experience • focusing on the client rather than the symptom -Interventions seek to increase client self-awareness and self-understanding -Holistic • assumes an interrelationship between the client's psychological, biological, social, and spiritual dimensions Q: Humanism is often referred to as the in psychology Answer: "third force" in psychology -after psychoanalysis and behaviorism Q: Humanism eventually gave way to a later force: Answer: transpersonal psychotherapy Q: early forces of psychotherapy Answer: Behaviorism -focuses on observable behaviorPsychoanalysis -studies the unconscious mind Humanistic-existential -focuses on individual free will Q: Types of Humanistic—Existential Therapy Answer: Person-Centered Therapy Gestalt Therapy Q: Person- or Client-centered therapy Answer: -Carl Rogers founded this psychotherapy in the 1940s role of the psychotherapist is to establish a therapeutic relationship -using genuine understanding and acceptance • client can discover and explore their reality. -belief people are essentially trustworthy, have potential for self-understanding & self-directed growth with support of a therapeutic relationship -congruence (genuineness and realness) -unconditional positive regard (acceptance and caring) -accurate empathic understanding through skilled, active listening (perceiving the client's subjective experience) • Positive belief in human nature • Self-concept (Self-worth, self-image, ideal self) • Actualizing tendency • Fully functioning person Q: goal of person-centered therapy Answer:assist the client to become a fully functioning person -role of the person-centered psychotherapist • provide client with unconditional positive regard to help facilitate change • Using congruence, acceptance, and empathy Q: Person- or Client-centered therapy indications Answer: -useful modality for individuals, groups, and families -effective in addressing a range of client problems • anxiety disorders, substance abuse disorders, psychosomatic problems, agoraphobia, interpersonal difficulties, personality disorders • often used in crisis interventions such as illness or the death of a loved one • recently demonstrated (+) outcomes with autism, transgender & gender diverse clients Q: Techniques used in person-centered psychotherapy Answer: -nondirective-facilitative counseling -congruence, unconditional positive regard -accurate empathic understanding Q: Gestalt psychotherapy Answer: -founded by Fritz and Laura Perls -holistic, person-centered therapy -assumption that while an individual may come close to understanding the experience of another, one can never fully comprehend another's experience • therapist observes how the client relates to the environment and moves from one experience to the next -three key philosophies • Field theory: context of the situation or field • Phenomenology: what is obvious rather than on the therapist's interpretation • Dialogue: showing the true self and experiencing the other person as they truly areQ: Gestalt psychotherapy: role and function of the therapist Answer: -inviting the client into an active partnership • learn about themselves • experience how they are in the present moment • explore new behaviors • focusing on the here and now rather than past experiences -addresses the clients' nonverbal body language • gestures as cues to rich info that the client may not be aware of -emphasize language patterns and personality Q: Key concepts of Gestalt psychotherapy: Answer: -figure and ground • how ind organizes their environment moment to moment -organismic self-regulation • when equilibrium is disturbed, the organism regulates themselves to restore order -layers of the personality • disowned parts of the self that create inauthentic layers of the personality -interruptions • protective resistances or defenses used to safeguard against fully experiencing a present moment experience Q: Gestalt psychotherapy Indications Answer: -used in individual or group settings -effective in addressing a range of client problems • medical disorders such as traumatic brain injury • helping adolescents overcome divorce trauma • helping individuals work through difficult dreamsQ: goal of Gestalt therapy Answer: help restore clients to a natural state of self-regulation -through the reintegration of disowned parts of the self • completion of unfinished gestalts Q: Techniques used in Gestalt psychotherapy Answer: -I-Thou relationship -creative experimentation • dreamwork • body awareness • focusing • empty-chair dialogues Q: Introjection Answer: occurs when a person uncritically accepts another's beliefs. Ex: Anders believes he should decline a leadership promotion at work because he was told by his father that he would never be a good manager. Q: Projection Answer: occurs when a person disowns aspects of themselves by assigning them to the environment. Ex: Greta did not meet an important project deadline at work and angrily ridiculed her husband for arriving home late.Q: Retroflection Answer: occurs when a person turns back on themselves what they would like to do to another. Ex: Mia's sister often yells at her about sharing clothes and doing household chores. Mia bites her lip intensely to avoid yelling back. Q: Confluence Answer: occurs when a person blurs the differentiation between the self and the environment. Ex: Tishon bullies a new kid at school to gain acceptance from a gang he wants to join. Q: Deflection Answer: occurs when a person uses distraction to avoid sustained contact. Ex: Farida constantly changes the subject when talking with her husband to avoid talking about their financial difficulties. Q: Humanistic theory Answer: -view personality with a focus on the potential for healthy personal growth towards selfactualization • Abraham Maslow's hierarchy of needs -Who am I -free will -people are inherently good-conscious -self motivated to improve -Carl Rogers • self-actualization nurtured in a growth-promoting climate • genuine • acceptance -Fritz Perls • Gestalt therapy, wholeness of ind's experience Q: Which theory would the psychiatric mental health nurse practitioner (PMHNP) most need to consider when conducting a psychiatric interview in the following situations? A 35-year-old homeless client is in the emergency department with suicidal ideations. Hierarchy of Needs Theory Psychosocial Development Theory Cognitive Development Theory Answer: Hierarchy of Needs Theory Rationale: To attend to higher-level needs, a client must first meet foundational needs. A homeless client may be struggling to meet physiological and safety needs. Q: Which theory would the PMHNP most need to consider when conducting a psychiatric interview in the following situations? A 14-year-old foster child struggling to develop trusting relationships with his foster parents. Hierarchy of Needs Theory Psychosocial Development Theory Cognitive Development Theory Answer: Psychosocial Development Theory Rationale: According to Erickson's theory, a developmental crisis in infancy trust vs. mistrust. When basic trust in caregivers is not developed in early life, it can impact the creation of trusting relationships later.Q: humanistic approach to nursing Answer: -Joyce Travelbee's humanistic approach to nursing • places emphasis on free will and the search for meaning in pain and illness -Josephine Paterson and Loretta Zderad • view nursing as a lived dialogue between the nurse and client -Jean Watson's Theory of Human Caring • nursing as caring action that regards clients with unconditional acceptance and positive regard Q: Which theory would the PMHNP most need to consider when conducting a psychiatric interview in the following situations? A 4-year-old is struggling to understand what she has seen on television about civil protests. Hierarchy of Needs Theory Psychosocial Development Theory Cognitive Development Theory Answer: Cognitive Development Theory Rationale: According to Piaget, children in early childhood do not have the cognitive ability to understand abstract concepts, such as justice. Q: Essential characteristics of the humanistic-existential approach: Answer: -focus on the phenomenological perspective -primacy of the therapeutic relationship -belief in holism -emphasis on the here and now -emphasis on humanistic-existential themes -centrality of process -use of experiential techniquesQ: Mateo is a 19-year-old transgender male who presents for therapy. He states that his gender identity is incongruent with his sex assigned at birth. He has transitioned to dressing as a man, goes by Mateo, his chosen name, and uses he/him pronouns at school and home. He states that he becomes very angry when people use his "dead" name or wrong pronoun. He states that he tries to correct the person, but he gets very frustrated when he must correct the same person repeatedly. The psychiatric mental health nurse practitioner (PMHNP) selects a client-centered approach to use in the psychiatric interview. Which of the following responses are congruent with client-centered psychotherapy? Select all that apply. "Why do you think you get angry when people misidentify you?" "It's ok if you are angry when people use your dead name." "Perhaps when people misidentify you, they are making a mistake. What might be a constructive w Answer: "It's ok if you are angry when people use your dead name." "I accept your gender identity and I understand that it is difficult when you interact with people who don't accept who you are." "It sounds like when people repeatedly use your dead name, you feel like they do not respect you." Rationale: Accurate empathic understanding helps the client to value their experiencing and increase their confidence in pursuing a course of action. The therapist can express genuineness, or congruence, towards the client. As the psychotherapist openly expresses feelings, thoughts, and reactions with the client, trust will be generated, and therapy will occur. During clientcentered therapy, the therapist should refrain from offering extensive advice and allow the client to drive the therapy session but may paraphrase the client's statements and repeat them to help the client clarify feelings and actions. Q: Josefina is a 24-year-old who presents for therapy. She reports she had been working as an exotic dancer to earn money. She endorses a long history of sexual promiscuity that started around age 13 when she experimented with sex with neighborhood boys. Since then, she has had serial relationships that leave her feeling abandoned. She recently got a job as a waitress and wants a "clean" start on her life. The psychiatric mental health nurse practitioner (PMHNP) selects a Gestalt approach to help Josefina in awareness attainment and skill development in regulating impulses. Which of the following are the most congruent with Gestalt therapy? Select all that apply. "What needs to happen today so that when you leave, you'll think this was a good session?""As you tell me your story, what are you experiencing?" "I noticed when you told me the story of your childhood sexual activity, your eyes began blinking. Can you give a Answer: "As you tell me your story, what are you experiencing?" "I noticed when you told me the story of your childhood sexual activity, your eyes began blinking. Can you give a voice to your blinking eyes?" "Would you agree to an experiment where you imagine each part of yourself in an empty chair?" "Would you be willing to say, 'I am finding it so difficult to find a partner?'" Rationale: Gestalt psychotherapy promotes understanding of the present experience rather than discussing situations in the abstract or focusing on the content of what the client reveals. Gestalt techniques are used to increase client awareness of what they are doing and how they are doing it. The statements: "What needs to happen today so that when you leave, you'll think this was a good session?" and "Was there ever a time when you felt happy in a relationship?" focus on content and finding solutions rather than the present experience. Q: Interpersonal psychotherapy (IPT) Answer: -shifts the emphasis of treatment to improving the quality of a client's interpersonal relationships and social functioning to help reduce psychological distress -form of time-limited, evidence-based, structured psychotherapy -social and interpersonal factors can impact symptoms of psychiatric disorders -focuses on the interactions between the self and others -purpose • relieve problems in interpersonal relationships and social adjustment to prevent the formation of additional psychiatric symptoms Q: Interpersonal psychotherapy (IPT) was developed by: Answer: Myrna Weissman and Gerald Klerman -in a research setting to study whether antidepressants in combination with psychotherapy provided better outcomes for clients with depression than antidepressant therapy aloneQ: Interpersonal psychotherapy (IPT) has shown efficacy in the treatment of: Answer: -Depression, perinatal depression, anxiety, and eating disorders -also been used in conjunction with social rhythm therapy in the treatment of bipolar disorder Q: developed the concept of attachment theory Answer: Bowlby -his studies of the maternal-infant bond -individuals form attachments to others and that separation or the threat of separation can lead to distress and depression Q: primary focus of IPT Answer: treatment of the social or interpersonal roots of depression -four interpersonal problem areas: • interpersonal disputes • role transitions • grief and complicated bereavement • interpersonal deficits Q: Characteristics of IPT Answer: -Time-limited: usually 12-16 weekly sessions -Focused -Based on current relationships -Interpersonal, not intrapsychic, cognitive, or behavioral -Aware of personality, but not focused on itQ: Role of the Therapist in IPT Answer: -help the client identify and address interpersonal issues • may be contributing to an exacerbation of psychiatric symptoms -communicate unconditional positive regard -provide an analysis of the client's communication skills -use techniques such as coaching or role-play • help the client improve communication skills Q: IPT Phases Answer: The initial phase -First three to four sessions -psychiatric hx & interpersonal inventory -1 of 4 interpersonal problem areas as focus of tx The middle phase -Active tx phase -uses the IPT model for selected problem to ID goals & address concerns -Allows client to explore experiences & create new relational patterns Termination -role transformation from acute therapy -Often overlaps with middle phase -Focus on concluding tx & addressing grief about loss of therapy & relationship with therapist -Therapist & client work together, review gains made in tx, assess future tx needs Q: IPT Therapeutic Techniques Answer: clarification, communication analysis, interpersonal incidents, role-playing, and problemsolving.Q: Daniela is a 35-year-old who presents with symptoms of apathy, sadness, and irritation. She states that she and her husband have been arguing for months about the division of labor associated with household tasks. Both Daniela and her husband work full time, but she states she "takes on the lion's share" of the work. She feels fed up and misunderstood. Which interpersonal problem area best fits this situation? Grief Role dispute Interpersonal deficit Role transition Answer: Role dispute Rationale: Role disputes occur in marital, family, social, and work settings when individuals have different expectations of a situation. The conflict leads to significant distress in at least one of the individuals. Q: Peg is a 46-year-old teacher and mother of one. She presents with symptoms of sadness and anger after learning that her husband of 15 years is gay and is planning to move across the country to live with a partner, leaving her to raise their da