I’m currently a student at the Silberman School of Social Work. This was the final paper for “Human Behavior 3.” HB3 is a required class which is basically a crash course in understanding and using the DSM-5 (The Diagnostic and Statistical Manual of Mental Disorders). In Human Behavior 1 and 2 they cover all kinds of ideas from psychodynamics to systems theory, and have the students practice writing biopsychosocial evaluations. I’m not sure what it looked like in the past but in recent years HB3 has become a DSM memorization class, so much so that we did most of the 5 week class online with modules that looked like the image I’m posting below. I don’t know what other people’s papers looked like, but here is what I turned in to my professor last week. Thanks so much to all the friends and people in this community who helped me out when I was losing it reading that Abnormal Psychology textbook last month!
Practice Case Study: “David”
Human Behavior 3
Sascha Altman DuBrul
Silberman School of Social Work
Case Study: “David”
David is a 21 year-old white male who presented at the local mental health clinic with his mother. She initially brought David to see the family’s primary care physician (PCP) with concerns about his increasingly odd behavior, and what she described as changes in his eating and sleeping patterns, hygiene habits, and overall daily routine. She was highly concerned was that David would not eat any food that was prepared by her in the home over the past several days.
David’s mother reported that he is an only child. His parents separated shortly after his birth, and he has always lived with his mother. She reported that he left high school in the 11th grade, following poor academic achievement and poor attendance. He had already been held back one grade but it was increasingly difficult for him to attend school, particularly since he endured teasing by other students. She reported that David had not pursued his GED or vocational training, but enjoyed creative writing. She enrolled him in writing classes at the local community college last year, but David left after he felt that the other students were attempting to sabotage his work by controlling him, his thoughts and his ideas. David has never worked nor does he have any friends. His mother recounted that David always presented differently from his peers but did not elaborate further.
Upon further assessment with David, he reported that he was angry with his mother for brining him to the clinic. He added that his mother has recently tried to harm him and stand in his way. He stated that she is attempting to poison him through the food she prepares. He also believes that she is monitoring his activities and preventing him from writing because she is attempting to interfere with his plan. When asked to elaborate on this plan, David reported that he has been directed by voices to share a message, through his writing, about the presence of outside forces, which are attempting to take over the world. He believes that he has been chosen to spread this message but that there are also voices of “non-supporters” who represent these outside forces. The “non-supporters” are attempting to alter his thoughts and influence his writing, so their threats to the world will not be revealed. David has recently stopped watching television because he believes that the outside forces are able to see him through the television, and also monitor his activities. David did not express fear or worry, and his affect remained flat throughout the session.
It is clear from David’s mother’s description that he has been struggling for a number of years with fitting into society (being teased, dropping out of school, never having a job) and that recently his behavior has shifted (unspecified eating and sleeping patterns, hygiene habits, overall daily routine.) By reading David’s narrative it seems obvious that he is experiencing delusions (outside forces attempting to take over the world), hallucinations (multiple conflicting voices he feels are coming from outside of him), and feelings of persecution (feeling his mother is trying to poison him.) We are told he has a “flat affect” when discussing these subjects and is angry about being brought to the clinic.
Common sense would suggest that David is experiencing a “psychotic disorder.” Psychotic disorders involve a loss of being in touch with reality and are characterized by abnormal thinking and sensory processes (Ray, 2015). I am drawn to the “Schizophrenia Spectrum,” section to learn more about the broad category of disorders referred to as psychotic disorders in the DSM-5 and try and diagnose David because of what appear to be the delusions and hallucinations he is describing. According to the DSM-5:
Schizophrenia spectrum and other psychotic disorders include schizophrenia, other psychotic disorders, and schizotypal (personality) disorder. They are defined by abnormalities in one or more of the following five domains: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms….(APA, 2013, P.87)
I am drawn specifically to the official descriptions of delusions and hallucinations:
Delusions are fixed beliefs that are not amenable to change in light of conflicting evidence. Their content may include a variety of themes (e.g., persecutory, referential, somatic, religious, grandiose). Persecutory delusions (i.e., belief that one is going to be harmed, harassed, and so forth by an individual, organization, or other group) are most common… Grandiose delusions (i.e., when an individual believes that he or she has exceptional abilities, wealth, or fame)…are also seen.” (APA, 2013, P.87)
David appears to be exhibiting “grandiose, persecutory delusions” that his mother is trying to poison him, that he has a mission to save the world, and that the outside forces are able to see him through the television and monitor his activities. Our initial assessment seems to fit with this first criteria. Furthermore, according to the DSM-5:
Hallucinations are perception-like experiences that occur without an external stimulus. They are vivid and clear, with the full force and impact of normal perceptions, and not under voluntary control. They may occur in any sensory modality, but auditory hallucinations are the most common in schizophrenia and related disorders. Auditory hallucinations are usually experienced as voices, whether familiar or unfamiliar, that are perceived as distinct from the individual’s own thoughts. (APA, 2013, P.87)
David reports that he has been directed by voices to share a message, through his writing, about the presence of outside forces, which are attempting to take over the world. He also describes a rich inner world of conflicting voices (“supporters” and “non-supporters”) that appear in the form of voices inside his head. This is a potential second criteria for a schizophrenia diagnosis. There are a few options for diagnosis that the DSM-5 provides including schizotypal personality disorder, schizoaffective disorder, schizophrenia, and brief psychotic disorder. David appears to potentially fit the description for someone with schizotypal personality disorder:
“The diagnosis schizotypal personality disorder captures a pervasive pattern of social and interpersonal deficits, including reduced capacity for close relationships; cognitive or perceptual distortions; and eccentricities of behavior, usually beginning by early adulthood but in some cases first becoming apparent in childhood and adolescence.” (APA, 2013, P.90)
On the other hand, since we have only encountered him for a short period, brief psychotic disorder might be an appropriate diagnosis as it lasts more than 1 day and remits by 1 month (APA, 2013, P.94)
Some other potential options are schizophreniform disorder, which is characterized by a symptomatic presentation equivalent to that of schizophrenia except for its duration (less than 6 months) and the absence of a requirement for a decline in functioning. Or schizoaffective disorder, in which a mood episode and the active-phase symptoms of schizophrenia occur together and were preceded or are followed by at least 2 weeks of delusions or hallucinations without prominent mood symptoms. In this initial assessment we do not see evidence of a mood disorder. Actual Schizophrenia lasts for at least 6 months and includes at least 1 month of active-phase symptoms, therefore it would take half a year before we would be able to give a conclusive diagnosis. (APA, 2013, P.96)
Other Puzzle Pieces and Questions to Ask
In order to understand the deeper layers of this story, it is significant that David is an only child, that his parents separated shortly after his birth, and that he has always lived with his mother. It would be very important to understand what kind of relationship he has, if any, with his father. It is obviously important that David endured teasing by other students. It is significant that he left high school in the 11th grade, following poor academic achievement and poor attendance. It is important to note that this reporting comes from his mother, we don’t known any back story from David’s perspective.
Some immediate questions I would ask David: how long has it been since he’s eaten? Since he’s slept? I would assess if there were any chance he’s been using street drugs. If I were talking to David directly I would want to assess his ability to focus on the present moment, ordinary topics, humor, his willingness to explore how others might perceive his ideas. More than anything, I would want to be clear that he was safe: is he thinking of hurting himself or others?
Psychosis as Teacher
All of that said, from the perspective of clinicians such as John Weir Perry, Michael Cornwall, and Arnold Mindell, any DSM diagnosis in the schizophrenia category is at best meaningless, and at worst, harmful, in being of service to people who struggle with what is considered psychosis.
According to psychotherapists like Perry and Cornwall, the key to working with David would be to begin by establishing a trusting connection with him so that “the painful emotion that is being metaphorically expressed via attributions of persecution, that have their genesis in early trauma, can start to emerge, be named by him, expressed directly, and integrated.” (Cornwall, M., personal communication. June 20, 2015.) It would involve way more than a few sessions with someone looking at a diagnostic manual for guidance. In fact, I believe this type of therapy, to be done well, must be practiced by someone who has a lot of life experience and a lot of compassion and desire to “travel” into the world of someone else’s shadows (Perry, 1974). There is so much rich material to explore from a metaphorical perspective, from David’s fears of being poisoned by his mother to his feelings that he has an important mission to save the world. David clearly needs allies and others to talk to who have been through similar situations and can relate to the complexities of his experience.
From this perspective, what we are calling psychosis is basically the psyche’s natural attempt to experience and express emotion that the person isn’t yet prepared to experience, identify and express. It is a calling from deep within a person for change and growth. This is a powerful reformulation of the disease model into something that looks more like a wounded healer model (Mitchell-Brody, 2007).
Arnold’s Mindell’s (1988) Process Oriented Psychology also sees psychosis as a potentially healing force. Mindell has developed a complex methodology for revealing the deeper meaning of bodily processes: feelings, pains, habitual gestures, even chronic illnesses. Whereas some therapies attempt to eliminate these processes, especially the ones considered negative or undesirable, Mindell’s approach is to amplify and follow them until they reveal what he sees as their hidden messages. Process Oriented Psychology uses the language of “extreme states” rather than “psychosis” (Williams, 2014). In Mindell’s view, psychosis is a term based upon the paradigm of pathology. “Extreme state” on the other hand is relativistic; it is neither good nor bad but simply says that someone’s experience is unusual relative to his world.
Working with David as a client would involve developing a relationship over time, paying very close attention to his speech patterns looking for “primary and secondary processes” (Mindell, 1992), and helping him feel understood and seen. I would be very interested in his writing and want to encourage him to express himself, get in touch with his dreams, all of his different inner voices, and give him inspiration and space to be creative with his thoughts and ideas. Using the Internal Family Systems model (Schwartz, 1997) I would attempt to teach him a meditation practice to get in touch with his inner Self, learn to see his voices as Exiles, Managers, and Firefighters and initiate a process of inner growth and development where his voices might become his teachers and guides.
While he spoke of outside forces being able to monitor him through the television and fear that his mother was trying to poison him, I was way more concerned to learn that David doesn’t feel like he has any friends. There are many people in our society who don’t have a peer support network, and the ability to connect to others is a key piece of healing and growth. Having others to share what are considered by society to be unusual and “psychotic” experiences can help enormously with feelings of isolation and stigma.
Two recommendations I would offer to David would be the peer-support community on The Icarus Project (DuBrul, 2014) website and its associated Facebook group. The Icarus Project offers a non-pathologizing frame for conditions that are often considered “mental illness”, specifically psychotic conditions. There are forums with names like “Experiencing “Madness” and “Extreme States”” or “Alternate Dimensions or Psychotic Delusions?” where many people like David have written extensively about their experiences and beliefs and can give feedback to one another. http://theicarusproject.net/ Online communication has many advantages for people who have issues with being social, and is a good first step in breaking out of the isolation that comes from struggling with what is often considered to be mental illness (Naslund, 2014).
Another option for David would be to attend a Healing Voices Support Group. The Hearing Voices Network, which began in Europe in the 1980s (Romme, 1992) is a collaboration “between professionals, people with lived experience, and their families to develop an alternative approach to coping with emotional distress that is empowering and useful to people, and does not start from the assumption that they have a chronic illness.”
At a Hearing Voices Support Group David would find others who also have experiences of voice hearing and it might help to normalize his experience and find enough common ground to make friends. http://www.hearingvoicesusa.org/
CBT For Psychosis
I’ve recently learned about the ways some of my colleagues are using a technique known as CBT For Psychosis to help people like David. The following text is taken from an introductory sheet about the process by Ron Unger LCSW (2014) and the points seem very relevant to our situation with David:
Normalizing: rather than identifying psychotic experiences as categorically different from “sane” experiences, focus on the continuum of human experiences, and notice the connections between psychotic experiences and more conventional ones. Explain to clients that in distressing or overwhelming situations, it is normal for unusual experiences to occur.
Therapist self disclosure is an important part of this type of therapy. Disclosing your own less normal experiences helps your client see the continuity between their own experience and yours. You are not saying that your own experience is the same as theirs, only that there are understandable connections and similarities.
A formulation is a way of understanding how the psychosis came about and what maintains it. In developing a formulation, you collaborate with the client in assembling a story that shows how the client’s psychotic experiences naturally came about as a result of the client’s history, which includes events intertwined with coping attempts and interpretations of experiences. The formulation should be condensed, such as one diagram or a written paragraph. But it can also be very inclusive, including predisposing, precipitating, perpetuating, and also protective factors, allowing for a clear understanding of what happened and of what is happening. It may change with time as you learn more.
Conclusion: Narrative Humility and the “Ethical Demand For Competence”
Given the little information we have, it is not clear to me that it is useful to try and draw any diagnostic conclusions about David’s behavior from this initial case study. According to Sayantani DasGupta (2004) from the Narrative Medicine program at Columbia University:
Narrative humility acknowledges that our patients’ stories are not objects that we can comprehend or master, but rather dynamic entities that we can approach and engage with, while simultaneously remaining open to their ambiguity and contradiction, and engaging in constant self-evaluation and self-critique about issues such as our own role in the story, our expectations of the story, our responsibilities to the story, and our identifications with the story—how the story attracts or repels us because it reminds us of any number of personal stories.
It feels very important in cases like that of David that we do not see him as an object, but as a subject, and that two interacting subjects (the client and the clinician) cannot act together unless some kind of mutuality between them has been established. This becomes very challenging when the clinician relates to the client as someone with a biological brain disease (Read, 2006).
There are questions from many very intelligent people (Lewis, 2006) (Whitaker, 2011) (Cooke, 2014) about the entire concept of “schizophrenia” and whether the current diagnosis actually has anything useful to add to clinical practice concerned with what is now considered severe mental illness. According to Polland & Caplan (2004):
The building of a narrow, pathology-oriented database poorly equips the clinician to understand what is wrong and what sorts of causal processes are in play in the person’s world or the clinical setting. In addition, an impoverished, pathology-oriented body of information fails to provide the basis for an adequate understanding of the person, their life, their goals, and their values.
I strongly agree with this statement, and as someone who has my own experiences being “treated” in the mental health system I feel that it is our duty as social workers to train and be trained as best as we possibly can to treat our clients not only with the personal respect that they deserve, but with an over arching world view that doesn’t begin by pathologizing their behavior as potential diseases and disorders. Part of my required reading for Human Behavior 3 was an essay by Lyter & Lyter (2012) entitled Diagnostic and Statistical Manual For Mental Disorders: Making it Work For Social Work, which spoke about the “ethical demands for competence” necessary for social workers. From the authors’ perspective, this meant using the DSM with “care and accuracy” (P.54), but from my perspective as a young clinician, competence means paying close attention to my own feelings, paying close attention to the internal world of my client, understanding the relationship between us, paying very close attention to as many factors as possible, and holding a space of love and understanding as much as possible. The DSM-5 cannot teach that. My Abnormal Psychology textbook cannot teach that. I think we do an incredibly disservice to the entire field of social work by placing so much emphasis on diagnosis.
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