Family Assessment ISSUU Visual Report NURS 480 Priscilla Sanchez

THE KELMECKIS FAMILY POST TRAUMATIC STRESS DISORDER & FAMILY SYSTEMS THEORY CALIFORNIA STATE UNIVERSITY SAN MARCOS, SCHOOL OF NURSING NURS 480 FAMILY HEALTH PRISCILLA SANCHEZ

INTRODUCTION Charlie Kelmeckis is a 16 year old male high school student who lives in the suburbs of Pittsburgh with his father, mother, older brother and sister.

Growing up, Charlie was closest to his Aunt Helen who also used to live with them. Aunt Helen used to spend a lot of time with Charlie, gave him presents, made him feel loved and belonged, and gave him books to read. However, on the night of his 7th birthday, she passed away due to a car accident. This impacted Charlie tremendously as she was the only figure in his life he confided and felt comfortable with. Additionally, when Charlie was in middle school, his best friend committed suicide, completely destroying Charlie and led him to attend sessions with a guidance counselor to cope with his death. As he enters high school, Charlie is still learning to cope with his best friend’s death. He realizes that he begins to get better as his relationships with the friends he’s made in high school, Patrick and Sam, strengthen. Due to unfortunate events in Charlie’s life growing up, it contributed to the development of his personality being shy, socially reserved, depressive moments, anxious, dissociative, and distant. It is eventually discovered by his family through his psychiatrist that Charlie was experiencing symptoms of PTSD due to childhood trauma of being sexually abused

by Aunt Helen growing up, in which he has suppressed the memory of it and replaced it with loving and caring memories of her. This ultimately results in the reason as to why he avoids intimate relationships with peers and family members, has problems making friendships and having social interactions in general, and experiences flashbacks and dissociation when he encounters triggering events, such as attempting to have sexual relationships. Although Charlie went through these unfortunate experiences growing up, he also had grown to be an extremely caring, thoughtful, and intelligent individual. He has learned to express himself through letters he writes to an anonymous “friend” and prefers to observe people to learn more about why people act the way they do. Throughout his high school years and acceptance of what has happened to him, Charlie then develops personal growth as he rebuilds his relationship with his family and is opening to creating new friendships.

MEMBERS OF THE KELMECKIS FAMILY 

Charlie’s Dad

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Charlie’s Mom

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43 years old

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40 years old

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Developmental Stage: Generativity vs. Stagnation

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Developmental Stage: Generativity vs. Stagnation

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Charlie’s dad initially comes off as having an authoritarian parenting styleuncaring and uninvolved, cold and emotionally distant, possibly even abusive as he slapped Charlie across the face after making his Aunt Helen cry before though instantly regretting it afterwards and promised to never hit Charlie again.

Although it becomes apparent that he does care about Charlie and his family, he is just not good at verbally expressing it. Charlie writes that he is “a very good husband” to his mother. Charlie’s dad was physically abused by his own father, therefore condones physically punishment in the household. He used to be a college basketball star and had a future ahead of him in that field however dropped out of college and his dream once he and Charlie’s mom became pregnant with their first child. Since then, Charlie’s dad has praised and lived through his oldest son’s athletic accomplishments. He is protective of his family and sacrifices a lot for them, and has shown to be kind and caring towards Charlie although simultaneously stern- displaying more of an authoritative parenting style.

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Charlie’s mom displays a permissive parenting style, as her family is whom she cares about most and she is not emotionally afraid to show it. She also experienced physical abuse from her dad growing up, which is what contributed to her emotional personality and at times it seems as though she is still recovering from it as well as the death of her sister from the car accident. Whenever Charlie’s dad disciples them, the mom is generally a quiet person and never speaks up against it. Charlie believes that she is a good mother and has found herself a good husband that does not hit her, such as her dad had done. He also believes that her mom has developed insecurities due to her abused past, in which he states his dad “calls her beautiful, but she cannot hear him”. She does not verbally express how much she loves her children, but it is acknowledged through her actions for them,

Chris Kelmeckis 20 years old Developmental Stage: Intimacy vs. Isolation Charlie’s brother is the oldest and most praised sibling of the family for his sports accomplishments. He currently attends Penn State for college football. He represents typical masculinity and the stereotypical jock- only dates “hot” girls and is obsessed with his car. He is displayed as a good older brother to Charlie, as he teaches him how to box when he heard a boy had been bullying him in school. He is away in college often but tries to visit his family as much as possible.

Candice Kelmeckis 18 years old Developmental Stage: Intimacy vs. Isolation Charlie’s sister is the middle child and a senior in high school. She is extremely bright as she proves to be a straight A student. She generally keeps to herself, but speaks out about topics that she is passionate about, such as women’s rights and the environment. Although she is smart, she finds herself trapped in an abusive relationship with her “secret” boyfriend. She is perceived as the mean sibling due to her seriousness, yet is shown to be genuinely loving and caring towards Charlie which later shows. She and Charlie eventually grow closer together as he drives her to get an abortion when she becomes pregnant.

Charlie Kelmeckis 16 years old Developmental Stage: Identity vs. Role Confusion Charlie is the youngest sibling and a freshman entering high school. He is emotionally unstable and cries often, subconsciously due to traumatic events from his past. He loves to read books and write essays for his advanced English class, contributing to his vision to become a write when he is older.. His professor recognizes him as “extremely special and intelligent”. He is a very loving passive person who enjoys observing others rather than participating. He begins to experiment with drugs throughout high school, such as weed and LSD. Over time, he learns a great deal about himself, his relationships, mental issues, and other problems high school students tend to deal with.

CHARLIE’S CONDITION: PTSD 

Post Traumatic Stress Disorder (PTSD) is categorized as a psychiatric disorder that develops in individuals who experience or witness traumatic events, such as natural disasters, accidents, war, abuse, or violent assault, or rape. This mental illness can occur in all people, of all ethnicities, nationality, culture, and age. 3.5% of US adults are diagnosed with this disease in their lifetime, with women having twice the likelihood of developing it than men. Symptoms of PTSD include intrusive thoughts (involuntary memories, flashbacks, distressing dreams of the event), avoidance of reminders/triggers, negative thoughts and feelings (distorted and compulsive beliefs about oneself and others, guilt and shame, feeling detached), and arousal and reactive symptoms (easily irritable, anger outbursts, self-destructive behavior, problems concentrating or sleeping).

To be diagnosed, symptoms need to last longer than a month and remain for months or years. PTSD also coincides with conditions, such as depression, substance use, memory problems, and other physical/mental health problems. Treatment options include Cognitive Processing Therapy, Prolonged Exposure Therapy, Group Therapy, medications (SSRIs & SNRIs), and other treatments including complementary and alternative therapies (ex. acupuncture or animal-assisted therapy) (Parekh, 2017).

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Charlie has been shown to display these symptoms of PTSD due to the childhood trauma he experienced of being sexually abused by his Aunt Helen. He displays symptoms, such as flashbacks, distressing memories, dissociative moments, distress and anxiety when exposed to triggers that resemble his trauma, and physiological reactions, such as shaking and crying. He also attempts to avoid situations and people that are associated with the event. He displays alterations in cognition and mood, such as being in denial and refusing to remember parts of the trauma, and holds negative feelings upon himself, blaming himself for what happened to him. Because of this, he also experiences feelings of detachment from others. This also leads to as to why he has been conditioned to distant himself from others, lacking social skills and relationship/friendships development. Additionally, this is also why Charlie is perceived as depressed and anxious most of the time, believing as though he is misunderstood causing him to feel lonely. Lastly, Charlie demonstrates anger outbursts due to his illness and begins to experiment with substance use. It is not until Charlie begins being treated with psychotherapy that he finally regains control of his life again.

STRENGTHS AND CHALLENGES OF THE KELMECKIS FAMILY Strengths 

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Challenges

The Kelmeckis family remains altogether and the parents offer unconditional support towards Charlie and his siblings.

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Lack of emotional connection/bond within the family.

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Lack of social interaction within the family.

Although the parents come off as distant, they are actually genuinely loving and care about their children very much- just have a hard time expressing it.

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Minimal understanding between each other initially.

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Siblings have a hard time getting along due to that feeling of disconnect.

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Family has a hard time verbally expressing how they feel towards one another, and sometimes have a hard time showing it as well.

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The parents become extremely emotional when they find out what happened to Charlie and why he is the way he is.

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Duvall’s developmental stage: Stage 5- Families with teenagers (oldest child 1320 years of age) Charlie’s parents are currently at the stage where most of their children are teenagers. Therefore, they are still responsible for their children but also are adapting to them finding their own way in the world.

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Routine/rituals: Charlie’s parents are emotionally distant/lack physical affection with their children because they grew up that way themselves. As a result, the siblings have grown to be distant from each other as well and lack social interactions with each other. However, they do show their own ways of loving one another and are all supportive of each other.

The parents do not get upset or blame Charlie for what happened to him when they find out through his psychiatrist- instead they are understanding about the situation and make him feel as though he is loved and belongs.

COMMUNICATION PRACTICES Verbal 

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Charlie’s family expressed that they loved Candice’s graduation speech, even though they did not. This shows that they may not be affectionate but they are supportive of the members no matter what.

Charlie tells Candice when she confides in him about her abusive relationship, “We accept the love we think we deserve.”

One of Charlie’s friend’s called his sister a tease and a snob, which he then told that person to never say anything like that about his sister again.

Charlie says about his family “I am very interested and fascinated by how everyone loves each other, but no one really likes each other.”

Nonverbal 

After finding out Charlie was molested by Aunt Helen as a child, she began to cry and hugged him to express her empathy and apology.

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Charlie and Candace share a hug and therapeutic touches as he is the only person she trusts and confides in about her abortion.

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Charlie was filled with joy and believed his sister really does love him when she gave him two hugs in a day, since they rarely show physical affection.

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Charlie’s father slapped Charlie when he made Aunt Helen cry, but instantly regretted it as evidenced by him crying uncontrollably afterwards.

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Charlie and Chris share hugs and therapeutic touches as they talk about bullies/school/fighting.

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Charlie’s mom made Charlie his favorite lunch because she knew he was feeling sad.

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Charlie’s dad gives Charlie “love pats” which are soft punches of encouragement that are administered on the knew, shoulder, and arm- these pats are how Charlie’s dad shows physical affection of love towards Charlie.

FAMILY SYSTEMS THEORY 

According to Family Systems Theory, the family is taken into account as a whole and individuals. Additionally, this theory emphasizes how the family is emotionally connected and a change in one member affects the whole. Stability is maintained through the structure and function of the family, which may have an adaptive or maladaptive outcome. Furthermore, the family is changed constantly in response to internal or external stressors in their environment. As nurses, tour goal is to restore or maintain stability within the family (Kaakinen, Coehlo, Steele, Tabacco, & Hanson, 2015).

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Based on this theory, one person in the family generally “absorbs” most of the emotions of the other members of the family, with this person most likely to suffer from depression, anxiety,, alcoholism, or physical illness- in this case, Charlie. To grow through these problems, therapy or counseling work best to bring the family together (ReGain, 2018).

Concept #1: All parts of the system are interconnected

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All members are affected by Charlie’s diagnosis and childhood trauma and they even visit him in the psychiatric hospital.

The family appears to be emotionally distant from one another, but do make efforts to be supportive and show affection in alternative ways.

Charlie recognizes that they are different in the way they interact with one another, however, still recognize them as a loving whole family.

Concept #2:The whole is more than the sum of its parts

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The death of Aunt Helen caused a major stress in the family’s life to all of the membersleading them to adapt to her loss.

The death of Charlie’s best friend growing up affected all members of the family, in which they became more empathetic and attempted to be understanding towards Charlie.

Even though Chris and Candice do not get along generally, they all come together and act as a happy family for special moments in the members’ lives- such as Charlie’s birthday and Candice’s graduation.

Concept #3: All systems have some form of boundaries or borders between the system and its environment    

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Charlie writes letters to an anonymous “friend” to express his emotions and thoughts because he prefers to keep his life private from his family.

Charlie’s family keeps his diagnosis and details of his past between the family only after being confided with by his therapist.

Charlie does not expose what his Aunt Helen did to him for a very long time because he did not believe she was in the wrong.

Candice does not expose her abusive relationship to any of the members, except Charlie.

All family members keep an emotional/affectionate distance from one another because the children learned from their parents who ultimately learned it from theirs.

Concept #4: Systems can further divided into subsystems   

Candice and Charlie share a close, growing bond after she confides in him about her abortion.

Chris tells Charlie that he feels closer to him than Candice because he perceives her as the mean sibling.

Chris teaches Charlie how to fight, which later he finds useful at school when he beats up a bully.

NURSING INTERVENTIONS & EXPECTED OUTCOMES Problem #1

Problem #2

Problem #3

Charlie’s lack of social interaction and inability create friendships due to negative feelings about himself and how he is perceived to others/lack of self-esteem and confidence. Whenever Charlie’s psychiatrist attempts to surface of his past to analyze the roots of these feelings of his, Charlie becomes in denial about it and simply believes he is “getting bad again”.

Members of the family do not notice Charlie’s signs of depression, flashbacks, irritability, or anxiousness. This leaves Charlie feeling as though he cannot open up to his family about his emotions because he’ll feel misunderstood. Therefore, he resorts to writing letters to his anonymous “friend”.

Charlie and his siblings receive no words of affirmation, therapeutic touches, or verbal/physical affection from their parents because their parents also did not grow up seeing/being showed it. Therefore, Charlie feels unloved at times and questions the dynamics of their family structure and wishes they were closer,

Intervention #1

Intervention #2

Intervention #3

Assess existing strengths and coping abilities, and provide opportunities for their expression and recognition. Demonstrate and promote effective communication techniques and support socialization and communication skills during sessions with the patient. Help the patient recognize that what happened to him was not his fault and the sooner he can accept that the sooner he will be able to move past it. Allow him time to adjust to his situation. Allow him in making choices regarding treatment and actively involve him in the decision process (Ackley et al, 2017).

Rationale: “Persons with psychiatric illness need help to stop their “negative self-image” and become more conscious of affirmative self-evaluation” (Kunikata, 2010).

Outcome #1 Charlie will attend his psychiatrist regularly, while following the prescribed regimen and relaxation practices outside of sessions. After following through with his medication and therapy, he will show a significant improvement in social interactions with others and will take imitative to create friendships in school setting. Furthermore, he will learn to cope with his diagnosis more efficiently and improve his self-esteem and build confidence.

Develop a trusting/therapeutic relationship with the patient and family.

Educate the family on signs and symptoms of depression and anxiety in adolescents. Also educate the family about PTSD and symptoms to look for in their child, since this is what Charlie is diagnosed with.

Furthermore, encourage journal/diary writing as a safe way of expressing emotions. (Ackley et al., 2017).

Rationale: “Members of the family may not have knowledge about their child’s condition, therefore, education and maintenance would be most important. Additionally, daily diary writing has been shown to decrease symptoms of depression” (Hopko & Mullane, 2008).

Use verbal and nonverbal therapeutic communication approaches, including empathy, active listening, and confrontation to encourage the patient and family to express emotions such as sadness, guilt, and anger, verbalize fears and concerns, and set goals (Ackley et al., 2017).

Rationale: Encouraging the family to express their emotions and using solution-focused communication will enhance coping.

Outcome #2

Outcome #3

The family members will gain a better understanding of Charlie’s condition and will know how to calm him down during times of stress.

Charlie will also feel more comfortable sharing his feelings and thoughts with his family, as well as continuing to write them in a journal.

Charlie and his family members will become a lot closer and gain a better understanding of one another. Their parents will not feel inclined to show verbal and physical affection towards their children. The siblings will also express signs of affection and support for one another. Their household will nurture a supportive, loving environment instead of an emotionally distant one, and Charlie will feel loved.

REFERENCES 

Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care. (11th ed.). St. Louis: Mosby, Inc. ISBN: 9780323085496

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Kaakinen, J., Coehlo, D., Steele, R., Tabacco, A., & Hanson, S. (2015). Family Health Care Nursing: Theory, Practice, and Research (5th ed.). Philadelphia, PA: F. A. Davis Company.

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McLeod, S. (2018). Erik Erikson’s stages of psychosocial development. Simply Psychology. Retrieved from https://www.simplypsychology.org/Erik-Erikson.html

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Parekh, R. (2017). What is posttraumatic stress disorder? American Psychiatric Association. Retrieved from https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd

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ReGain. (2018). Family systems theory definition & what is it? Retrieved from https://www.regain.us/advice/family/family-systems-theory-definition-what-is-it/

Image References 

Candice Kelmeckis [Image]. (n. d.) Retrieved from https://www.tumblr.com/tagged/candance

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Charlie and Aunt Helen [Image]. (n. d.) Retrieved from http://nataliecchs.weebly.com/classification-for-perks-of-being-a-wallflower.html

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Charlie and Aunt Helen [Image]. (n. d.) Retrieved from https://www.pinterest.com/pin/322218548309341670/?lp=true

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Charlie and siblings [Image]. (n. d.) Retrieved from http://theperksofbeingawallflowerinfo.weebly.com/resolution.html

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Charlie and siblings [Image]. (n. d.) Retrieved from https://gifer.com/en/P503

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Charlie crying [Image]. (n. d.) Retrieved from https://gifer.com/en/QiCH

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Charlie’s dad [Image]. (n. d.) Retrieved from https://www.youtube.com/watch?v=EOpvsEgDrsY

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Charlie’s dad [Image]. (n. d.) Retrieved from https://joesmoviestuff.blogspot.com/2014/09/the-perks-of-being-wallflower-2012.html

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Charlie’s mom [Image]. (n. d.) Retrieved from https://www.youtube.com/watch?v=rwPb9FQ96_c

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Charlie’s mom [Image]. (n. d.) Retrieved from https://www.youtube.com/watch?v=Nlxt3zcR_Pw

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Chris Kelmeckis [Image]. (n. d.) Retrieved from https://joesmoviestuff.blogspot.com/2014/09/the-perks-of-being-wallflower-2012.html

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Kelmeckis Family [Image]. (n. d.) Retrieved from https://theperksofbeingawallflowerge.weebly.com/book-response.html

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Younger Charlie & siblings [Image]. (n. d.) Retrieved from https://elizabethaltmeyer.weebly.com/the-perks-of-being-a-wallflower.html