Maria: I’m so pleased you can help us. We’re here because Marco is having such a hard time lately. I’m Maria, his Grandma, but he’s lived with me for twelve years, since he was two, when [strident, angry] his Mama went to jail for killing that no-good man she was living with. I know he’s Marco’s Dad, but he wouldn’t even ever marry her!

[sweetly] Juan and Elisa, they’re just 10 and 9, you saw them in the waiting room? They’re Marco’s cousins. My son Carlos’s babies. God rest their souls. Carlos and their mama died in a car crash six years ago. [sniffles]

I’m takin’ care of these kids the best I can. [deep sad sigh] They are my grandbabies after all and I’m all they got. But I been sick lately. Been in the hospital a couple times just this month. Julia, she goes to church with me, she took care of them all while I’s gone. But Marco here, he was so bad for her I’m not sure she’ll do it again if I get sick again.

Marco: I don’t understand why we’re here. I’m fine…I just want everyone to leave me alone. You know I don’t like to go out… I rather stay in my room and watch movies. Yeah, I don’t want to go to school. Who cares? I know you keep goin’ on about how my grades have dropped. But, geez, Grandma, what does it matter?

Maria: [distracted] Wait… Is that Juan and Elisa screaming out there? Just a moment…

Marco, I don’t know how to help you? I want you to be happy, and have dreams and aspirations. Remember, when you were two, you told me you wanted to be a firefighter? You gotta graduate to do that.

Marco: Who cares about the future? No one loves me. You’re always with Elisa and Juan.

[mocking] Grammy, help me. Grammy, feed me. Grammy, play with me.

[muttering darkly] You never have time for me. [deep angry sigh]

Maria: Oh, honey, we do love you, and I want you to be a role model for Juan and Elisa and get better so you can help me take care of them. I always counted on you before. But what happened? Like when Julia had to come. You could have helped so much. But you didn’t!

Marco: Acho Julia? La alcahueta that didn’t even come once to my room to check on me! Why? Because I don’t matter, I’m not important… If I were, Mom would be here with me! But no, she’s in jail. And, and I hate to visit her there. I get nervous, angry, and start sweating [getting quieter] ‘cause I’m afraid to end like them all in there. I mean, she’s my Mom and I got her genes.

You know, I feel like that when I go to school. Everything starts to close in, and I’m so scared someone is going to ask me about my parents. What the hell would I tell them? My mom’s in jail cuz she killed my dad. That’ll win me some friends!

When I think about school… I don’t wanna eat, I feel sick, an’ can’t sleep.

Maria: [gently] I want you to get help, Marco. That’s why we’re here.

Marco: Anda pa’l carajo! Like anyone can help me. Everyone keeps saying I’m not a “nice” person or, well, you know they use worser words. I hear it at school and at home. It hurts to listen to that and feel worthless sometimes.

Answer the following questions from your perspective as Marco’s psychiatric nurse practitioner.

  1. Identify the steps you would take and the techniques you would use to develop a therapeutic alliance with Marco and Maria. Would you include Juan and Elisa in the assessment process? Why or why not?
  2. You decide to complete a genogram. How would you explain the purpose and function of the genogram to Marco and Maria?
  3. Discuss what information the genogram could provide to you. Explain how that information could be used to develop a treatment intervention strategy.

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