Sunday, October 27, 2013

ASSESSING THE CASE OF SOPHIE & NATHAN FROM SOPHIE'S CHOICE. A FURTHER LOOK AT DOMESTIC VIOLENCE, SUBSTANCE ABUSE, POST TRAUMATIC STRESS DISORDER & SCHIZOPHRENIA

   

Recently, I watched a movie called “Sophie’s Choice.” Two of the main characters are named Sophie and Nathan who live at a boarding house in Brooklyn NY. Throughout the movie, these characters exhibit several different behaviors that may be due to individual mental illness. These behaviors also negatively affect how Sophie and Nathan interact within their personal relationship and socially with others. Therefore, the overall purpose of this work is to write a case evaluation that first diagnosis which mental disorder each character may have. I will then provide all pertinent findings, treatment recommendations and any ethical considerations that might apply during their overall assessment and treatment plans.
Case Name: Sophie Zawistowska
Background Information
Sophie is a polish catholic and survivor of the Holocaust. During her time there she was also forced to give up her daughter to be exterminated and her son was sent away never to be seen again. She doesn’t have a college level education but is bilingual and possesses a high level of overall writing and secretarial skills. These were acquired after working for her father translating documents during the Second World War. She is currently unemployed with no source of income so she relies on her boyfriend Nathan for financial support. She also believes that he saved her life because she was extremely ill after being released from the concentration camp and he provided her treatment. Sophie also has scars on her wrists from an attempted suicide but she did not disclose whether she received any psychological help to address the issues that may have caused this behavior. 
Behavioral Observations
Sophie is an extremely intelligent woman who always wears nice dresses and is well groomed. She interacts well with others but has a slight issue trying to fully understand the English language and which words should be used. Her mood is normally pleasant unless she experiences a psychological and/or physical altercation with her boyfriend Nathan or discusses certain remnants of her past. During these times she exhibits emotional behavior that is associated with being a battered woman or guilt and anxiety from certain choices that she made in her past. 
Diagnoses
309.81 Posttraumatic Stress Disorder (Chronic Type)
Other Conditions That May Be a Focus of Clinical Attention:
Physical Abuse of Adult (V61.1)
Findings
After considering Sophie’s background information and current behavior, I would diagnose her with Post Traumatic Stress Disorder (PTSD). The main reason for this diagnosis is because according to (DSM-IV-TR. 1995-2013), “when an individual who has been exposed to a traumatic event develops anxiety symptoms, reexperiencing of the event, and avoidance of stimuli related to the event lasting more than four weeks, they may be suffering from this particular Anxiety Disorder.” Research has also shown that most people who suffer with this disorder may have also experienced abandonment and/or severe neglect as children. 
In Sophie’s case, she was exposed to traumatic events that were threatening to the lives of her and her children. This included having to sacrifice the life of her only daughter to save her only son which caused intense feelings of fear, helplessness, and horror at the time of occurrence. Since, this increased level of trauma occurred I suspect that Sophie has continuously recalled the events through cognition of distressing mental images, perceptions or thoughts. However, since these may cause her great psychological distress, she chooses to use total avoidance of the events as a major coping mechanism. This includes continuously making a conscious effort to avoid all feelings, thoughts, or conversations associated with the events.
Since, Sophie lives her life trying to avoid these haunting aspects from her past, it has also caused a feeling of being detached or estranged from many others. One example of this is when she thinks about the "choice" that she made as a mother and it makes her believe that she has less worth than all other mothers. She also exhibits a slight restricted range of affect and high sense of a foreshortened future. Some examples of this are when she always tells Nathan that she is going to die and when telling Stingo that she’ll probably never be able to love him, live a normal life in Virginia or be a good mother for his children.
She also changes the room around at night because she can’t sleep and seems to exhibit an exaggerated startle response during certain physical situations with Nathan. I believe that she is exhibiting these behaviors because she doesn’t want to have nightmares that are associated with her past trauma or experience further physical abuse at the hands of her loving partner. Since, these issues have occurred for several years Sophie also exhibits significant levels of distress or impairment in other areas of functioning. Therefore, she has also become majorly dependent on Nathan to meet her social, economic, psychological and physical needs.
Furthermore, I also believe that Sophie has been a repeated victim of physical abuse during the course of her relationship with Nathan. This occurs because when he experiences certain symptoms associated with his mental illness while abusing substances, he becomes physically violent and aggressive toward her. There are also repeated scenes in the movie when she is crying and tries to conceal visible bruises that he has left on her body. Although, she says that his abusive behavior is okay and allows it to continue due to her extreme level of overall dependency on him.
Treatment Recommendations
When reviewing Sophie’s case, there are some major issues that would need to be addressed. The first one is her psychological need to use avoidance to deal with her past. This is a major issue because it’s preventing her from dealing with feelings of guilt and shame in an appropriate and healthy manner. I would also treat this issue by using one-on-one talk and exposure therapy. This way, she would be able to verbally expose issues from her past in a safe environment and learn coping skills that can be used to manage her overwhelming level of guilt and shame. 
Furthermore, I would also prescribe a selective serotonin reuptake inhibitor to reduce the intensity of these negative feelings. This is because according to (Jaffe & Schub. 2012), “selective serotonin reuptake inhibitors (SSRIs) are the first-line medications used to treat PTSD and are the only medications approved by the U.S. Food and Drug Administration (FDA) for treatment of PTSD.” Finally, I would refer Sophie to an agency that helps women who are victims of domestic violence. This is because she may be able to receive beneficial services like further counseling, a safer place to live and group therapy with other victims.  
Prognosis
When reviewing all of the details of Sophie’s case, I don’t believe that she would do well in treatment and that her overall prognosis is less than fair. This is because if she continues to live in her current environment, further abuse from Nathan will most likely occur and she won’t have the positive support system that is needed to fully recover from her severe level of long-term PTSD. Having a positive support system and acquiring treatment are also major requirements for people who develop this disorder after experiencing trauma because it can reduce symptoms and initiate a faster recovery time. However, up to this point she has only received positive support from their mutual friend Stingo who knows little about PTSD. 
I am also confident that she will never acquire the motivation that is needed to end her relationship with Nathan due to her growing dependency and skewed belief that he is her savior. Therefore, her feelings of guilt and shame will probably get worse and she may also begin to experience issues like low self-esteem and worthlessness due to ongoing occurrences of severe psychological and physical abuse.
Ethical/Legal Considerations
When conducting an assessment and treatment plan for Sophie, I will also need to address any ethical concerns that may apply. This is because following ethical standards will help ensure that her rights are protected throughout the overall process. Four specific ethical codes that may also apply to her individual case include:
1. Informed Consent – According to this standard, professionals must inform participants of all features which might affect his or her willingness to participate. This is important because clients will be informed about the overall purpose and it gives them an option to participate or withdraw. I will also implement this by having Sophie sign a written document that identifies the overall content and purpose of the assessment and treatment plan.   
2. Debriefing – This states that all professionals should debrief each client before, during and after the process. This is important because it can ensure that clients are aware of all beginning, ongoing, and final results that may be obtained. This can also allow the opportunity to address any misconceptions that clients may have during the overall process. I could also implement this by ensuring that Sophie was kept informed about all important findings.
3. Protection From Harm – This means that I will need to get permission from Sophie prior to treatment and if any aspects of treatment may be harmful to her I will avoid using them.
4. Confidentiality – This standard protects the rights of clients by mandating that personal information can only be released under specific circumstances. Following this law is important because it can ensure that no harm occurs to the client due to personal information being released in a malicious or damaging manner to third party members. However, according to (BACB Guidelines For Responsible Conduct), a behavior analyst can “disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose, such as (1) to provide needed professional services to the individual or organizational client, (2) to obtain appropriate professional consultations, (3) to protect the client or others from harm, or (4) to obtain payment for services, in which instance disclosure is limited to the minimum that is necessary to achieve the purpose” (p.4). Since, this is the case I may be required to report some of Sophie’s personal information to specific third parties that can further assist her. This is because she is a victim of domestic violence which is a crime and she may also be a danger to herself due to an unstable psychological state and/or mental disorder.
Client Name: Nathan
Background Information
Nathan is 29 years of age and from a Jewish descent. He currently lives in Brooklyn with his girlfriend Sophie and states that he is a biologist but his brother says that he actually works at a library. He claims that he graduated from Harvard University but his brother dispels that lie as well by saying that Nathan has no college education and is regularly abusing cocaine. Furthermore, he was diagnosed with Paranoid Schizophrenia at the age of 10 and has been in and out of mental institutions. The symptoms that are associated with this particular disorder are also still present.
Behavioral Observations
Nathan is an extremely intelligent man who often wears nice suits and is well groomed. He interacts well with others unless he experiences a psychotic episode. This is when his mood changes and he becomes extremely agitated, angry, paranoid, and delusional. During this time, he also psychologically and physically abuses Sophie on a severe level. Furthermore, he also has delusions of grandeur which make him believe that he is a brilliant biologist and almost every aspect of his daily life is consumed by this fabricated way of thinking. 
Diagnosis
295.30 (Schizophrenia) Paranoid Type This type of schizophrenia involves a preoccupation with delusions or auditory hallucinations. In order to diagnose a client with this disorder, he or she must also still have organized speech and non-catatonic behavior.
Other Conditions That May Be a Focus of Clinical Attention:
Substance Abuse and possible Bi-Polar Disorder 
Findings
After reviewing Nathan’s background information and long-term behavior, I diagnosed him with Paranoid Schizophrenia because he meets the criteria for that disorder. This is because he exhibits the following symptoms and/or behavior:
1. Clinically significant distress – He feels bad after he hurts Sophie due to his disorder.
2. Mood changes with periodic hypomania – He becomes agitated and physically abuses Sophie.
3. Anger that is dealt with by using repression, denial or paranoid projections – He often psychologically attacks Sophie by calling her names and accusing her of cheating on him.
4. Delusions of grandeur or auditory hallucinations – He believes that he graduated from Harvard University and is a brilliant biologist who is working on groundbreaking research.
Treatment Recommendations
When reviewing Nathan’s case, there are major issues that need to be immediately addressed. The first one will be to try and reduce the overall level of symptoms that are related to Paranoid Schizophrenia. According to (Butcher., Mineka & Hooley. 2010), an individual with this type of schizophrenia “shows a history of increasing suspiciousness and of severe difficulties in interpersonal relationships” (p. 463). The symptoms that seem to be most relevant with Nathan are his mood changes with hypomania, paranoid projections, anger, and delusions of grandeur. 
The main reason that these symptoms should be treated as soon as possible is because he is causing psychological and physical harm to Sophie when they appear. These symptoms are also preventing him from being able to live in a normal state of reality. I would begin treating his disorder by verbally teaching him certain coping skills that can be used to manage these symptoms and prescribe an antipsychotic medication to try and reduce the intensity of symptoms and number of episodes. 
Furthermore, I would also refer Nathan for an additional assessment to address possible Bi-Polar Disorder and to agencies that help with domestic violence and substance abuse. This is because he may be able to receive beneficial services like further counseling, a neutral place for discussion, and group therapy with others who are experiencing the same issues.
Prognosis
When reviewing all of the details of Nathan’s case, I don’t believe that he will do well in treatment and that his overall prognosis is poor. This is because if he continues to live in his current environment, further abuse to Sophie will most likely occur when mood changes with hypomania and/or paranoia are present. Therefore, he won’t have the positive support system that is needed to combat symptoms that are associated with his severe level of long-term Paranoid Schizophrenia. Having a positive support system and acquiring treatment are also major requirements for people who develop this disorder because it may reduce these symptoms. 
However, up to this point he has been in and out of several mental institutions and has not improved. I am also confident that he will never acquire the motivation that is needed to end his relationship with Sophie due to his growing obsession and skewed belief that he is her grand savior. Therefore, his symptoms will probably only get worse and he may also begin to experience issues like self-hate and depression due to his continuous psychologically and physically abuse toward Sophie.
Ethical/Legal Considerations
When conducting an assessment and treatment plan for Nathan, I would also need to address any ethical concerns that may apply. This is because following ethical standards would help ensure that his rights were protected throughout the overall process. Five specific ethical codes that may apply to her individual case include:
1. Informed Consent – This means that I will need to inform Nathan about all features that might affect his willingness to participate. I will also implement this by asking him to sign a document that identifies the content and purpose of the assessment and treatment plan.  
3. Debriefing – This means that I will need to debrief Nathan before, during and after the assessment and treatment process. This is important because it will ensure that he’s aware of all beginning, ongoing, and final results that are obtained. This will also allow the opportunity to address any misconceptions that he may have during the overall process.
4. Protection From Harm – This means that I will need to acquire permission before treating Nathan and if any aspects of treatment may harmful, I will avoid using them.  
5. Confidentiality – This states that personal information can only be released under specific circumstances. The BACB Guidelines For Responsible Conduct also state that a professional can disclose confidential information without a client’s consent to protect the client or others from harm. In Nathan’s case, I would be forced to release some of his personal information to third parties. This is because he carries weapons, has threatened others safety and has already caused severe psychological and physical harm to Sophie. Since he is experiencing delusions of grandeur about who he is and what he has become, I also don’t believe that he is competent enough to make important decisions so involuntary hospitalization may be required in the future.  
Summary
This was written after watching a movie called “Sophie’s Choice” which includes two main characters named Sophie and Nathan. There are several scenes in the movie that depict different behaviors which may be associated with individualized mental illness. These behaviors and/or symptoms also negatively affect how Sophie and Nathan are able to interact as a couple and with others in various social settings. Therefore, the overall purpose of this work was to first provide a case evaluation for each character that confirms which mental disorder/s they may have. I then followed each diagnosis with any pertinent findings, treatment recommendations and ethical considerations that may apply to each case. 

References:

American Psychiatric Association(2000). BehaveNet: APA Diagnostic Classification DSM-IV-TRRetrieved on February 1 2013 via the World Wide Web at http://behavenet.com/apa-diagnostic-classification-dsm-iv-tr 

Behavior Analyst Certification Board. (2004). Guidelines for responsible conduct for behavior analysts. Retrieved on February 2 2012 via Kaplan Online at http://content-asc.kaplan.edu.edgesuite.net/PS502_1004A/images/product/Guidelines%20for%20Responsible%20Conduct.pdf

Butcher, J. N., Mineka, S., & Hooley, J. M. (2010). Abnormal Psychology (14th Ed.). Boston, MA. Allyn & Bacon, Pearson Higher Education.

Pakula, Alan (Director and Producer). (1982). Sophie’s Choice. (DVD). Lions Gate

Schub, T., Jaffe, S. (2012). Post-traumatic stress disorder. Retrieved on February 3 2013 via the Kaplan Library at http://ehis.ebscohost.com.lib.kaplan.edu/eds/pdfviewer/pdfviewer?sid=b008d357-ffce-4487-b4b6-7d2bd37572c9%40sessionmgr11&vid=9&hid=2