Abnormal Psychology - Clinical Persps. on Psych. Disorders, 6th ed. - R. Halgin, et. al., (McGraw-Hill, 2010 WW-91-95

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Case Report

Peter Dickinson

Treatment Plan

After only a brief interaction with Peter during our ﬁ rst encounter, I knew that he needed to be hospital- ized. As is common when dealing with individuals in a manic state, there was a tremendous amount of resistance to such a suggestion, however. I realized that Peter would balk at my recommendation, so I was prepared to make my viewpoint as unambiguous

as possible. In my thoughts, I realized that there was no way that I would feel comfortable sending Peter back out onto the streets. Of particular

concern was the intensity of his anger toward Marnie. Might he threaten to harm her in some way? It seemed unlikely, but possible. What

did seem likely, however, was that Peter would not be able to take ade- quate care of himself in this disor

- dered state of mind.

I explained to Peter that I was deeply concerned about his psychological state and that I was prepared to commit him. Not only did I consider him to be a possible dan- ger to others, but I feared for his physical and psychological well- being. As I had anticipated, Peter began ranting and raving in re- sponse to this. At one point, he jumped up and began yelling that I had no authority to push him around.

I knew that it was important for me to let him know that I was not in- timidated. In a gentle but dete

r- mined voice, I explained to Peter that I was prepared to take this ac- tion, which I was quite clear was in his best interest. Even I was sur

- prised, however, by Peter’s sudden turnaround. Apparently, on some level, he recognized that he was out

of control. He was then able to ac - cept help in regaining his stability . Peter admitted to me that the dis- turbed reaction of his brother, Don,

to his outlandish behavior had helped him realize that “something was seriously wrong.”

Peter admitted himself voluntarily to the hospital, asking me to “prom- ise” that he would be discharged within 2 weeks. I explained that a 2-week time frame seemed reason- able, but providing a guarantee was

too difﬁ cult, because I was not sur e how quickly he would respond to treatment.

My treatment recommendations for Peter were relatively straightfor

- ward. First, he needed medication to help control his manic symptoms.

Beginning Peter on lithium made sense, because this medication has proven to be effective in the treat-

ment of mania. Second, Peter needed to begin a course of psychotherapy that would have several compo- nents. In individual therapy, Peter

could work with me in developing an understanding of the nature and causes of his psychological distur

- bance. We would also discus

s choices he could make to reduce the amount of stress in his life and to manage his symptoms over the longer course. In addition to individual

therapy, I suggested that Peter’

s mother and brother join Peter for a few family therapy sessions to be conducted by Bev Mullins, the tr

eat- ment unit’s social worker. Family

therapy would focus on establishing a more stable source of emotional connection between Peter and his immediate family. The beneﬁ ts of such an improved alliance would

be multiple. Those most concerned about Peter could be available for support in the event that his distur

- bance reappeared. Furthermore, hi

s mother’s personal experience with the same disorder could serve as an invaluable source of insight into the nature and treatment of this condition. Group therapy was the third form of therapy I recommended to Peter. During his stay on the treatment unit, he would participate in

three groups a week, during which he would share his experiences with others who were also strug- gling with the powerful experiences

associated with a psychological di s- order. With expressions of reluc- tance, Peter agreed to go along with my plan.

Outcome of the Case

As it turned out, Peter’s stay in the hospital lasted precisely 14 days.

He had shown dramatic improvement after only 4 days on lithium, at which

point he expressed relief that he was now calmer and “getting back to normal.” For the ﬁ rst time in several weeks, he was able to get some

sound sleep and return to normal eating habits.

In his sessions with me, Peter told the story of a troubled child- hood, having been raised by a mother with extreme and unpredictable mood variations. Making matters worse, his mother saw Peter, the younger of the two boys, as the son in whom she could conﬁ de. By doing so, she set up an uncomfortable alliance with him, and he felt unduly responsible for her well-being.

After graduating from high school, Peter didn’t choose the col- lege route taken by most of his classmates; instead, he eloped with his girlfriend and took a job at a lo- cal convenience store. Peter and his wife fought almost constantly—

mostly about money issues—for the 4 years of their marriage, but they had developed an emotional depen- dence on each other that made separation seem too difﬁ cult. When his wife ﬁ nally threw him out of the house, he was devastated and found himself burdened by feelings of depression and rage. In the weeks that followed the break

up, he “bottomed out.” He couldn’t work, eat, sleep, or think clearly

. At one point, he came close to making a suicide attempt one night while driving alone in his car. Instead of acting on his impulse, he pulled over to the side of the road and cried until dawn. Eventually, over

subsequent weeks, the depression subsided. Following a period of rel- ative serenity, however, he found himself unbelievably energized and

traveling down the path to mania.

During Peter’s stay in the hospital, we met six times. In these sessions, he was able to see how stressors in his life brought on a mood disorder to which he was biologically predis- posed. His ongoing interpersonal and ﬁ nancial difﬁ culties placed him at in- creased risk, and, when his marriage broke up, the psychological turmoil reached a level too intense for him to tolerate.

R E T U R N T O T H E C A S E

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Case Report

Peter Dickinson

In the three family sessions Bev Mullins conducted, Peter’s mother

and brother were remarkably re- sponsive in communicating their concern and support. For the ﬁ

rst time that Peter could remember, Mrs.

Dickinson acknowledged the turmoil that her mood disorder must have created for Peter, as well as the pres- sures she placed on her young son to help her solve her problems. In

an emotionally charged session, all three family members were brought to tears as they spoke of the hurt a

nd confusion of years past. They

also became closer to each other, as they spoke of ways they would try to mak

e their relationships different in the months and years to come.

As successful as individual and family therapy proved to be for Peter , the same was not true for grou

p therapy. Although the group was scheduled to meet three times each

week, Peter refused to attend the meetings during the second week of his stay in the hospital. He asserted that, since his symptoms had gone

away, he had nothing in common with the “psychos in the therapy group.” This issue had the potential of becoming the basis of a power struggle between Peter and the treatment staff. Peter realized that he would be forfeiting some uni

t privileges, but he was ﬁ rm in his in- sistence. Although I would have pr

e- ferred that he participate, I realized

that on some level he was trying to make a statement about his need to be autonomous. Because he was so cooperative in every other way, and he did not balk about the administra-

tive consequences of his choice, I decided to let the issue rest.

As we approached the point of discharge, I asked Peter what his preference would be regarding af- tercare. He asked me if I would be willing to continue seeing him for “a couple more weeks.” I believe that Peter realized that his condition war

- ranted a longer term of follow-up therapy. I pointed out to Peter that he had been through a bout with a major psychological disorder. Even though he was feeling ﬁ ne, he was still vulnerable, and ongoing treatment made sense. I remember the tone of his sarcasm as he asked

me,

“So how many weeks of therapy do I need, Dr. Tobin?” I responded that 6 months of regular follow-up sessions, perhaps one every other week, would be most helpful. At that point, we would re-evaluate and make a decision about subsequent treatment. He went along with my plan and responded quite positively

in our work, every other week, for the following 6 months. He continued to take lithium, and there was no evidence of mood symptoms through-

out that period.

At the end of 6 months, Peter had made some important life changes.

He had applied for a job as a bank teller, and he had enrolled in an ed- ucational support program in which the bank subsidized part-time col- lege courses. Once he had made this move, Peter communicated that he was “feeling OK” and that he wanted to reduce the frequency of sessions to once a month. I con- curred with this plan. What I was less comfortable with, however

, was Peter’s decision to stop taking lithium. He felt that he was over his “sickness” and that he didn’

t want to take medication he no longer needed. I reviewed the risks with him, but I respected his right to

make his own decision. Five months went by, and Peter was doing very well, when suddenly he found himself feeling energized and “high.

” He called me with a tone of eupho- ria in his voice to cancel our session, and I sensed that he might once again become manic. He responded to my urgent request that he come in for a session that day . With great ambivalence, he followed my recommendation to re-

sume his medication.

We met monthly for another year, and now Peter contacts me, usually with a brief phone call once every year, on the day after his birthday

, to let me know that “all’s well.”

Sarah Tobin , PhD

SUMMARY

■ Nearly half the population is affl icted with a diagnosable psychological disorder at some point in their lives. Approxi- mately 25 percent of these people seek professional help from clinicians, 15 percent from other professional sources;

the remainder rely on informal sources of support or go without help. Clinicians are found within several professions, such as psychiatry, psychology, social work, nursing, and family counseling. They are professionals who are trained to be objective observers of behavior, facilitators of growth, and resources for people facing diffi cult situations.

■ Clinicians and researchers use the Diagnostic and Statistical Manual of Mental Disorders, fourth edition ( DSM-IV-TR ), which contains descriptions of all psychological disorders.

In recent editions, the authors of the DSM have strived to meet the criterion of reliability, so that a given diagnosis will be consistently applied to anyone showing a particular set of symptoms. At the same time, researchers have worked to ensure the validity of the classifi cation system, so that the various diagnoses represent real and distinct clinical phe- nomena. The development of the most recent edition, the

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66 Chapter 2 Classifi cation and Treatment Plans

ANSWERS TO REVIEW QUESTIONS

Psychological Disorder (p. 40)

1. Patient is used to refer to someone who is ill and, consis- tent with the medical model, who waits to be treated.

Client refers to a person seeking psychological treatment, and this term refl ects the fact that psychotherapy is a collaborative endeavor.

2. Comorbid 3. 21

The Diagnostic and Statistical Manual of Mental Disorders (p. 50)

1. Reliability refers to the extent to which a given diagnosis is consistently applied to anyone showing a particular set of symptoms. Validity refers to whether the diagnosis represents a real and distinct clinical phenomenon.

2. Axis 3. Axis III

KEY TERMS

Differential diagnosis 52 Evidence-based practice in

psychology 62 Family therapy 61

Global Assessment of Functioning (GAF) scale 50

Group therapy 61 Halfway house 60

Individual psychotherapy 61 Milieu therapy 61

Modality 61 Multiaxial system 45 Neurosis 44

See Glossary for defi nitions Axis 45

Base rate 41

Case formulation 53 Client 38

Clinical psychologist 40 Community mental health center

(CMHC) 60 Comorbid 39

Culture-bound syndromes 59 Day treatment program 60 Decision tree 51

Diagnostic and Statistical Manual of Mental Disorders (DSM) 40

Patient 38

Principal diagnosis 52 Prognosis 50

Psychiatrist 40

Psychological testing 40 Psychosis 44

Reliability 41 Syndrome 43 Validity 41 DSM-IV-TR, involved a three-stage process, including a

comprehensive review of published research, thorough anal- yses of the research data, and fi eld trials. The authors of the DSM consider a phenomenon a mental disorder if it is clinically signifi cant; if it is refl ected in a behavioral or psychological syndrome; if it is associated with distress, impair- ment, or risk; and if it is not expectable or culturally sanctioned. The DSM-IV-TR is based on a medical model orientation, in which disorders, whether physical or psychological, are viewed as diseases. The classifi cation system is descriptive rather than explanatory, and it is categorical rather than dimensional. Diagnoses are categorized in terms of relevant areas of functioning, called axes: Axis I (Clinical Disorders), Axis II (Personality Disorders and Mental Retardation), Axis III (General Medical Conditions), Axis IV (Psychosocial and Environmental Problems), and Axis V (Global Assessment of Functioning).

■ The diagnostic process involves using all relevant information to arrive at a label that characterizes a client’s disorder.

Clinicians fi rst attend to a client’s reported and observable symptoms. The diagnostic criteria in DSM-IV-TR are then considered, and alternative diagnoses are ruled out by means of a differential diagnostic process. Going beyond

the diagnostic label, clinicians develop a case formulation, an analysis of the client’s development and the factors that might have infl uenced his or her current psychological status. Clinicians also attend to ethnic and cultural contribu- tions to a psychological problem.

■ Once a diagnosis is determined, a treatment plan is developed. The treatment plan includes issues pertaining to immediate management, short-term goals, and long-term goals. A treatment site is recommended, such as a psychiat- ric hospital, an outpatient service, a halfway house, a day treatment program, or another appropriate setting. The modality of treatment is specifi ed and may involve individual psychotherapy, couple or family therapy, group therapy, or milieu therapy. The clinician will also approach the treatment within the context of a given theoretical perspective or a combination of several perspectives. After a plan is developed, clinicians implement treatment, with particular atten- tion to the fact that the quality of the relationship between the client and the clinician is a crucial determinant of whether therapy will succeed. Although many interventions are effective, some are not. Mental health professionals know that change is diffi cult and that many obstacles may stand in the way of attaining a positive outcome.

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INTERNET RESOURCE

To get more information on the material covered in this chapter, visit our website at www.mhhe.com/halgin6 e.

There you will fi nd more information, resources, and links to topics of interest.

The Diagnostic Process (p. 57)

1. Decision tree 2. Case formulation

3. The clinician would begin by consulting the culture-bound syndromes in the DSM-IV-TR in order to determine whether the client’s symptoms might best be understood in this context.

Treatment Planning (p. 62)

1. CMHCs are outpatient clinics that provide psychological services on a sliding scale for individuals living within a certain geographic area.

2. Effi cacy; effectiveness

3. Best available research evidence; clinical expertise; and context of the cultural background, preferences, and charac- teristics of clients

Internet Resource 67

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C H A P T E R 3

Assessment

O U T L I N E

Case Report: Ben Robsham 69 What Is a Psychological

Assessment? 70 Clinical Interview 70

Unstructured Interview 70 Structured and Semistructured

Interviews 71

Mental Status Examination 74 Appearance and Behavior 74 Orientation 75

Content of Thought 75 Thinking Style and Language 76 Affect and Mood 77

Perceptual Experiences 78 Sense of Self 79

Motivation 79

Cognitive Functioning 79 Insight and Judgment 79 Psychological Testing 79

What Makes a Good Psychological Test? 80 Intelligence Testing 81

Personality and Diagnostic Testing 84 Behavioral Assessment 89

Behavioral Self-Report 90 Behavioral Observation 91 Multicultural Assessment 91

Real Stories: Frederick Frese:

Psychosis 92

Environmental Assessment 93 Physiological Assessment 94

Psychophysiological Assessment 94 Brain Imaging Techniques 95 Neuropsychological Assessment 97 Putting It All Together 98

Return to the Case 99 Summary 100

Key Terms 101

Answers to Review Questions 101 Internet Resource 101

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