Thompson Family Case Study Discussion: Post-traumatic Stress Disorder
Discussion: Posttraumatic Stress Disorder
It is estimated that more than 6% of the U.S. population will experience posttraumatic stress disorder (PTSD) in their lifetime (National Center for PTSD, 2010). This debilitating disorder often interferes with an individual’s ability to function in daily life. Common symptoms of anxiousness and depression frequently lead to substance abuse issues and even physical ailments. For this Discussion, as you examine the Thompson Family Case Study in this week’s Learning Resources, consider how you might assess and treat clients presenting with PTSD.
Learning Objectives
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Students will:
Assess clients presenting with posttraumatic stress disorder
Analyze therapeutic approaches for treating clients presenting with posttraumatic stress disorder
Evaluate outcomes for clients with posttraumatic stress disorder
To prepare:
Review this week’s Learning Resources and reflect on the insights they provide.
View the media Academic Year in Residence: Thompson Family Case Study, and assess the client in the case study.
For guidance on assessing the client, refer to pages 137–142 of the Wheeler text in this week’s Learning Resources.
Note: To complete this Discussion, you must assess the client, but you are not required to submit a formal Comprehensive Client Assessment.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the ”Post to Discussion Question” link and then select ”Create Thread” to complete your initial post. Remember, once you click Submit, you cannot delete or edit your own posts, and cannot post anonymously. Please check your post carefully before clicking Submit!
By Day 3
Post on or before Day 3 an explanation of your observations of the client William in Thompson Family Case Study, including behaviors that align to the PTSD criteria in DSM-5. Then, explain therapeutic approaches you might use with this client, including psychotropic medications if appropriate. Finally, explain expected outcomes for the client based on these therapeutic approaches. Support your approach with evidence-based literature.
References American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.
Standard 3 “Outcomes Identification” (pages 48-49)Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company
In the Thompson family case study, William exhibits several key identifiers for the diagnosis of post-traumatic stress disorder (PTSD). According to the Diagnostic and Statistical Manual (DSM-5); the exposure to actual or threatened death, serious injury or sexual violence (in a specific way) is one of the main criteria for a PTSD diagnosis in adults (DSM-5, 2013). Our client William is an Iraq war veteran who has undoubtedly seen and experienced unspeakable situations during the war. Also, in the case study, William seems to be avoiding the thought of his PTSD. The National Institute for Mental Health (2017), states that one of the classic symptoms of PTSD is avoidance of thoughts or feelings related to the traumatic event. William also doesn’t seem to acknowledge his diagnosis as he states “they say I have PTSD.” A common co-occurring symptom of PTSD is substance use disorder (Dworkin, Wankly, Stasiewicz, & Coffey, 2018). Our client has an alcohol addiction which has compromised his job as an attorney and has added multiple stressors to his family.
Therapeutic approaches that I would use with William as my client include cognitive behavioral therapy (CBT). The use of CBT in PTSD has been proven to help clients reduce negative symptoms while improving everyday functioning (American Psychological Association, 2018). According to the National Institute for Mental Health (2017) the main treatment for clients who present with PTSD is medication therapy and psychotherapy. First line therapy for clients who are experiencing PTSD are SSRI’s such as Sertraline 25 mg PO daily. Sertraline has been studied to show clinical efficacy in clients with PTSD with comorbid alcohol dependence (Alexander, 2012). SSRI’s have been associated with a 60% response rate in clients with PTSD (Alexander, 2012). Expected outcomes for William after receiving CBT and an SSRI will aid in greatly improving his impairments in daily functioning.
Leonie
Reference
Alexander W. (2012). Pharmacotherapy for Post-traumatic Stress Disorder In Combat Veterans: Focus on Antidepressants and Atypical Antipsychotic Agents. P & T: A peer-reviewed journal for formulary management, 37(1), 32-8. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278188/
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.
American Psychological Association. (2018). Posttraumatic stress disorder. Cognitive Behavioral Therapy. Retrieved from https://www.apa.org/ptsd-guideline/treatments/cognitive-behavioral-therapy.aspx
Dworkin, R., Wanklyn, S., Stasiewicz, R., Coffey, F. (2018). PTSD symptom presentation among people with alcohol and drug use disorders: Comparisons by substance of abuse. Addictive Behaviors, 76(1), 188-194. Retrieved from Walden Library databases.
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
1 MICHAEL THOMPSON DISCUSSION GUIDE THE LUPUS INITIATIVE
Developed by the Georgetown University National Center for Cultural Competence – August 2015
CASE STUDY DISCUSSION GUIDE
Michael Thompson
Assumptions, Attitudes and Biases:
What Patients and Health Care Professionals Believe can Delay Diagnosis and
Effective Treatment
PURPOSE
This guide is designed to accompany the Michael Thompson case study
and to provide guidance to those responsible for leading discussion
groups with residents. The guide includes conceptual frameworks and
definitions for culture, cultural competence, and linguistic competence;
key takeaways points; content to inform dialogue on the reflection
questions; references; and suggested resources. While the guide
provides an array of information, the references and resource list offer
additional sources to enhance learning and professional development in
providing culturally and linguistically competent care to patients who
have lupus.
GETTING ON THE SAME PAGE
The following provide a list of key terms and their definitions. Engage the residents in discussion about
these concepts and to make sure they are “on the same page” and using terms in the same way.
What do we mean by culture? Culture is perceived of and defined in many different ways. Have group
members discuss their definitions and understanding of culture and how culture impacts both health
and health care.
The following is a definition of culture used by the Georgetown University National Center for Cultural
Competence:
Culture is the learned and shared knowledge that specific groups use to generate their behavior
and interpret their experience of the world. It comprises beliefs about reality, how people should
interact with each other, what they “know” about the world, and how they should respond to
the social and material environments in which they find themselves. It is reflected in their
religions, morals, customs, technologies, and survival strategies. It affects how they work,
parent, love, marry, and understand health, mental health, wellness, illness, disability, and
death.
Culture includes but is not limited to—thought, communication, languages, beliefs, values,
practices, customs, courtesies, rituals, manners of interacting, roles, relationships, and expected
behaviors of an ethnic group or social groups whose members are uniquely identifiable by that
pattern of human behavior.
1
2 MICHAEL THOMPSON DISCUSSION GUIDE THE LUPUS INITIATIVE
Developed by the Georgetown University National Center for Cultural Competence – August 2015
While the aforementioned definition and conceptualization present culture in terms of the group and
group behavior, it is essential to note however, that aspects of culture are manifested differently in each
person. A member of a cultural group may neither exhibit nor embrace all of the beliefs, values,
practices, modes of communication, or behaviors attributed to a given group. This understanding of
culture recognizes the individuality of human beings and the unique diversity among group members.
This may include but is not limited to race, ethnicity, age, gender, gender identity, socioeconomic status,
education, profession, country of origin, languages spoken, and the lived experience of chronic illness,
disability, or mental illness. Importantly, accepting this understanding of culture minimizes the tendency
to stereotype and reminds us that one’s cultural identity is influenced by a constellation of interrelated
and distinct factors. This conceptualization of culture also acknowledges professional culture,
specifically the culture of medicine and its impact on one’s values, beliefs, and world view.
Lastly, it is important within the health care context to expand our conceptualization of culture beyond
individual people and groups to organizations, systems, and the socio-cultural contexts of communities
in which patients and their families live. Health care practices, organizations, and systems have their
own cultures – norms, rules, language, decision-making processes, approaches to communication,
defined roles and responsibilities, ways of interacting with those seeking and receiving care. Figure 1
illustrates this concept by depicting the multiple dimensions of culture that converge and how they are
integrally linked in health and health care. Figure 1 asks you to consider the cultures of the patient,
his/her family, the health care practitioner, the health care practice/organization, and cultural contexts
of the communities that impact health and well-being of patients.
3 MICHAEL THOMPSON DISCUSSION GUIDE THE LUPUS INITIATIVE
Developed by the Georgetown University National Center for Cultural Competence – August 2015
Take away points
The following take away point offer insight about culture within the context of health and health care.
Understanding another culture is a continuous and not a discreet process.
It takes experience as well as study to understand the many subtleties of a culture other than
your own.
Culture informs attitudes, beliefs, and practices of individual patients and their families who
seek and use health care.
You are a cultural being and have multiple cultural identities, one of which is your profession – a
physician or health care practitioner.
You view and interpret the world through your own cultural lens which is comprised of both
individual and group experiences over time.
Your world view influences how you deliver health care. This world view may or may not be
shared by the patients and families to whom you provide health care.
You are influenced by the culture of the practice or organizational setting in which you provide
health care.
What do we mean by cultural competence?
Encourage the group to discuss their conceptualizations and definitions of cultural competence. This will
allow group members to hear how the concept of cultural competence has been taught in medical
education and is understood and practiced in residency. Acknowledge that there are many definitions
of cultural competence. Some definitions focus on the health care practitioner and others at the system
or organizational level. Have the group to discuss the following definition and how it consistent with or
different from their understanding of the concept of cultural competence at both levels.
The Georgetown University National Center for Cultural Competence embraces a definition that of
cultural competence that requires organizations:
• have a defined set of values and principles, and demonstrate behaviors, attitudes, policies and
structures that enable them to work effectively cross-culturally.
• have the capacity to (1) value diversity, (2) conduct self-assessment, (3) manage the dynamics of
difference, (4) acquire and institutionalize cultural knowledge and (5) adapt to diversity and the
cultural contexts of the communities they serve.
• incorporate the above in all aspects of policy making, administration, practice, service delivery
and involve systematically consumers, key stakeholders, and communities.
Cultural competence is a developmental process that evolves over an extended period. Both individuals
and organizations are at various levels of awareness, knowledge and skills along the cultural
competence continuum. 2
4 MICHAEL THOMPSON DISCUSSION GUIDE THE LUPUS INITIATIVE
Developed by the Georgetown University National Center for Cultural Competence – August 2015
Cultural competence at the individual level
requires
the capacity to:
1. Acknowledge cultural differences that exist
between patients, their families, and health
professionals and how such differences impact
health care. Demonstrate valuing these
differences, for example, in your manner of
communication with patients and their
families and partnering in medical decisionmaking.
2. Understand your own culture- willingness to reflect upon your own cultural belief systems,
including the culture of medicine, and how they influence your interactions with patients and their
families.
3. Engage in self-assessment – responding to assessment instruments/checklists and taking time for
self-reflection to examine one’s own attitudes, values, and biases that may contribute to or
compromise positive patient-provider relationships and your approach to health care.
4. Acquire cultural knowledge and skills – pursuing formal and informal opportunities to learn about
the cultures of your patients, the environments in which they live including the social determinants
of health, culture-specific and evidence-based practices and interventions to improve health care
outcomes.
5. View behavior within a cultural context – even if a behavior seems illogical, seek to understand the
beliefs or practices of patients (without judgement) and partner with them to overcome problems
that may compromise their health and well-being. This may involve spanning the boundaries or
health care to engage with social services and others in the helping professions. 3-5
Take away points
Cultural competence:
is a developmental process and is enhanced over time, at both the individual and organizational
levels.
must be supported by organizational policy, procedures, practices, and resources.
is an intentional, evidenced-based practice and involves gaining knowledge and skills in order to
provide care that is effective and acceptable to diverse patient populations.
involves examining one’s own beliefs and attitudes about patient behaviors including one’s
biases and stereotypes about patients.
5 MICHAEL THOMPSON DISCUSSION GUIDE THE LUPUS INITIATIVE
Developed by the Georgetown University National Center for Cultural Competence – August 2015
Discussion of Reflection Questions
Why do you think Mr. Thompson feels he may have made a mistake coming to the emergency room
for care?
Engage participants in a discussion of this question and use the information below to inform the
discussion.
1. Assumptions
The clerk made an assumption that because Mr. Thompson
is African American he is poor. While intake processes are
supposed to ask for insurance information, individuals
conducting those procedures have been shown to make
erroneous assumptions about the patients with whom
they interact. A great deal of training and effort has been
directed at supporting health care and other professionals
to provide culturally and linguistically competent services
and supports. For most patients, however, many
interactions precede the actual encounter with the health care provider. Families must make
appointments, ask questions about insurance, check in and provide information at each visit, and be
escorted in to see the practitioner or professional. These encounters are typically with staff in the health
care provider’s office or in a hospital, clinic, or agency setting. Patients’ experiences in getting services
are affected as much, if not more, by these interactions than by their encounters with the health care
provider. Unfortunately, too many families continue to encounter the insensitivity, lack of courtesy and
respect, bias, and even discrimination in their experiences with the front desk. For more examples
consider sharing the following document Cultural Competence: It all starts at the Front Desk.
6
2. Lived experience of racial bias
Mr. Thompson’s reaction to the clerk’s assumptions about him might be seen in the context of his
ongoing experience of interactions that reflect bias and stereotyping within his life. While overtly racist
comments and actions may be less common, there is a phenomenon that has been described as
microaggressions. “Racial microaggressions are brief and commonplace daily verbal, behavioral, or
environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory,
or negative racial slights and insults towards people of color.” 7 Those that inflict racial microaggressions
are often unaware that they have done anything to harm another person. For Mr. Thompson,
encountering bias and stereotyping at the beginning of his care has reinforced his attitudes that seeking
healthcare will not be positive experience and likely reminded him of other such interactions. Often, in
discussions of racial bias and stereotyping, the issue arises that “people are just too sensitive.” Consider
enhancing the discussion with questions that ask participants to reflect on times when someone has
made an assumption about them based on factors other than race or ethnicity — such as age, gender,
gender identity or expression, profession, or religion. The goal is to engender an ability to take another’s
perspective—a key skill for culturally competent health care professionals.
6 MICHAEL THOMPSON DISCUSSION GUIDE THE LUPUS INITIATIVE
Developed by the Georgetown University National Center for Cultural Competence – August 2015
What assumptions did the nurse make about Mr. Thompson and why he didn’t have a regular source
of medical care?
How might her assumptions affect Mr. Thompson’s health care experience?
What should health care professionals know about the cultural beliefs of the patients they serve?
How can they learn about those beliefs?
Using the information below, engage participants in their responses to the questions above.
3. More and more assumptions
The nurse made an assumption about why Michael did not have his own doctor and why he has not
sought care earlier. She assumed that it was financial barriers that prevented him from seeking ongoing
care. There were multiple assumptions wrapped together, including an assumption that because he is
African American he is poor and costs were the barrier to care. Culturally competent health care
providers know to ask patients about their reasons for a particular behavior—whether it is not seeking
health care or not following through on recommended treatments. The patient’s belief systems or
personal, family, and community contexts or practical barriers impact behavior. Cultural competence is
achieved by identifying and understanding the needs and help-seeking behaviors of individuals and
families.8 Culturally competent health care providers know that culture provides the context for all
behavior— yours and your patient’s. Learning about the health beliefs and practices of the
communities one serves through reading, opportunities for community members to teach and share
their perspectives, and engaging in activities within communities one serves are effective methods to
enhance cultural competence. It is important to recognize that each individual has his or her own set of
beliefs and values. Asking patients in a non-judgmental way about why they have chosen a particular
behavior is a key to culturally competent and patient-centered care and can open up a discussion that
can lead to mutually agreed upon recommendations for health behaviors.
How can racial bias affect health care?
Can well-meaning and fair-minded health care providers have and act on racial biases without
knowing it?
Engage participants in discussing these questions. The following information can be used to inform the
discussion.
4. Multiple manifestations of bias
It is important to understand bias and its multiple manifestations in our efforts to address lupus-related
disparities and inequities. The Institute of Medicine (IOM) concluded in 2003 that “bias, stereotyping,
prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and
ethnic disparities in health care”.9
Although health care practitioners, whose professions epitomize
helping others, find it very difficult to accept that they may indeed harbor biases that result in
differential treatment and care provided to their patients, bias is an attribute that exists in all humans as
a natural sociobiological process.10 The obligation of health care practitioners is to become aware of
their biases and take action to mitigate the effects.
7 MICHAEL THOMPSON DISCUSSION GUIDE THE LUPUS INITIATIVE
Developed by the Georgetown University National Center for Cultural Competence – August 2015
There are two types of bias identified in the literature. In the case of
explicit or conscious, the person is very clear about his or her feelings and
attitudes and related behaviors are conducted with intent. This type of
bias is processed neurologically at a conscious level as declarative,
semantic memory, and in words. Conscious bias in its extreme is
characterized by overt negative behavior that can be expressed through
physical and verbal harassment or through more subtle means such as
exclusion. 11-13
Implicit or unconscious bias operates outside of the person’s awareness
and can be in direct contradiction to a person’s espoused beliefs and
values. What is so dangerous about implicit bias is that it automatically
seeps into a person’s affect or behavior and is outside of the full
awareness of that person. Implicit bias can interfere with clinical assessment, decision-making, and
provider-patient relationships such that the health goals that the provider and patient are seeking are
compromised.14
Implicit bias has been demonstrated to impact clinical decisionmaking. Findings have reflected differences in care or proposed care
based on race and ethnicity for cardiac conditions, HIV/AIDS, end
stage renal disease, psychiatric treatment, surgical safety and
outcomes, and treatment of pain, among others. A complex array of
factors contributes to the impact of implicit biases on decisionmaking. 15-17 Fatigue, stress, and cognitive overload are closely linked
to health care practitioners and the environments in which they
work. In high demand, high performance situations, practitioners are vulnerable to the “hard wiring”
employed by the brain to circumvent cognitive overload by simplifying information through group
generalizations and stereotyping. Ultimately, such behaviors result in biased or compromised medical
decision-making that cannot be fully explained by specific clinical factors of the patients involved. 18-23
A suggested activity
There are a number of self-assessment tools and instruments designed to help you learn about
unconscious or implicit bias. One such tool is the Implicit Association Test (IAT), developed by a team of
leading cognitive scientists and rigorously researched.
https://implicit.harvard.edu/implicit/demo/background/thescientists.html.
While the IAT was developed to research unconscious bias, it is now available to those interested in
learning about themselves.
It is good to point out that taking the IAT can be a little unsettling. Remind group members that it
measures unconscious bias and even those who are fair minded and detest prejudice at a conscious
level, often turn out to have some unconscious biases based on race, age, gender, and other factors.
There is an in-depth, free CME activity provided by the Lupus Initiative of the American College of
Rheumatology for those who want to learn more about unconscious or implicit bias in health care, how
it operates, and how to address it.
8 MICHAEL THOMPSON DISCUSSION GUIDE THE LUPUS INITIATIVE
Developed by the Georgetown University National Center for Cultural Competence – August 2015
Conscious and Unconscious Bias in Health Care: A Focus on Lupus
• Epidemiology, Disparities, and Social Determinants of Lupus
(0.5 credit hour)
• Defining Bias and its Manifestations and Impact of Bias on Health and Health Care
(1.0 credit hour)
• Even Well-Meaning People have Bias
(0.5 credit hour)
• Well- What’s a Well-Meaning Health Care Professional To Do?
(1.0 credit hour)
Why is it important for health care providers to have knowledge about incidence of diseases, disease
presentation, and appropriate treatments based on factors such as gender, race, ethnicity, and sexual
orientation?
Engage participants in discussing this question. The information provided below can be used to inform
the discussion.
5. Attending to cultural factors in disease incidence, presentation, and treatment
Cultural factors (i.e., gender, race, ethnicity, sexual orientation) that
represent types of diversity in patient populations, are important
variables in understanding the patient. In the past much of the
research conducted on disease incidence, disease presentation, and
effective treatments was typically done on men and mostly white men
(non-Hispanic). Researchers are increasingly taking an approach that
helps delineate differences based on race, ethnicity, gender, sexual
orientation, and other factors. In some cases, presentation can differ.
For example, Canto, et. al.,24
examined research over 35 years and
found that between 30-37% (depending on the study) of women did not
have chest discomfort during a heart attack compared with 17-27% of
men. Women were more likely to report other symptoms such as pain in
the back, neck or jaw, loss of appetite, cough and others. Lack of chest
pain was noted to be an impediment to accurate diagnosis. As already
noted in the modules, SLE is more common in women, but does occur in
men and may have a somewhat different presentation. Effectiveness of
medications has been linked to factors such as gender, race and ethnicity
as well. Culturally competent clinicians acquire the knowledge that allows
them to develop a nuanced and differentiated approach to diagnosis and
treatment based on the most recent evidence. Lack of such knowledge can
impact accurate and timely diagnosis
There are both biological differences that impact these factors as well as differences in interactions with
the healthcare system, approaches to health promotion and healthy behaviors, and exposure to risk
factors. Culturally competent clinicians do not take a deterministic view of these factors; rather they use
9 MICHAEL THOMPSON DISCUSSION GUIDE THE LUPUS INITIATIVE
Developed by the Georgetown University National Center for Cultural Competence – August 2015
the knowledge from the literature within the social and economic contexts of the patients they are
treating.
What can health care providers do to better communicate complicated health information?
How can they be sure they have successfully communicated that information?
Engage participants in discussing these questions and use the information below to inform the
discussion.
6. Communicating in plain language
The literature has documented that when information is not
communicated in a way that patients can understand, they
cannot or do not follow through with healthcare
recommendations. While the physician knows that the findings
of “active urinary sediments” is of great concern, Michael does not.
Even individuals with a high level of education, such as Michael,
may not have d detailed knowledge of highly technical medical
terminology and information. It is easy for healthcare
professionals to become so used to their “language” that they do
not realize they are not sharing information in a way that is easy
for patients to understand. One simple way to be sure that a
patient understands and can act on information is to use the
Teach Back method25 http://www.teachbacktraining.org/
This method basically asks a patient to tell you what you have
just told them. It is a good check on how effectively you have
communicated important information. Effective
communication is key to building a trusting relationship with
patients.
From the Teach Back Training website:
10 Elements of Competence for Using Teach-back Effectively (PDF)26
1. Use a caring tone of voice and attitude.
2. Display comfortable body language and make eye contact.
3. Use plain language.
4. Ask the patient to explain back, using their own words.
5. Use non-shaming, open-ended questions.
6. Avoid asking questions that can be answered with a simple yes or no.
7. Emphasize that the responsibility to explain clearly is on you, the provider.
8. If the patient is not able to teach back correctly, explain again and re-check.
9. Use reader-friendly print materials to support learning.
10. Document use of and patient response to teach-back.
10 MICHAEL THOMPSON DISCUSSION GUIDE THE LUPUS INITIATIVE
Developed by the Georgetown University National Center for Cultural Competence – August 2015
References
1. Gilbert, J., Goode, T. D., & Dunne, C. (2007). Cultural awareness. Curricula Enhancement Module
Series. Washington, DC: National Center for Cultural Competence, Georgetown University Center for Child and
Human Development. Retrieved on 8/18/15 from
2. National Center for Cultural Competence. Conceptual Frameworks, Models, Guiding Values and Principles.
Retrieved on 8/18/15 from http://nccc.georgetown.edu/foundations/frameworks.html
3. Goode, T. Bronheim, S. & Jackson, V. The Essential Role of Cultural Competency in Addressing Racial and
Ethnic Health Disparities in the African-American Community. In Leonard, J. (Ed.) Diabetes in Black America:
Public Health and Clinical Solutions To A National Crisis. Munster, IN: Hilton Publishing, 2010.
4. Goode, T., Wells, N., & Kyu, Rhee (2009). Family-Centered, Culturally and Ling
